Provider Demographics
NPI:1609211564
Name:KASSEN, LAURIE JEAN (RD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:KASSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:JEAN
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:8270 W LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8511
Mailing Address - Country:US
Mailing Address - Phone:952-200-0890
Mailing Address - Fax:
Practice Address - Street 1:8270 W LAKE CT
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8511
Practice Address - Country:US
Practice Address - Phone:952-200-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005817133V00000X
MN1453133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered