Provider Demographics
NPI:1629850128
Name:MICK, TIANA GUNNAR (RD)
Entity Type:Individual
Prefix:
First Name:TIANA
Middle Name:GUNNAR
Last Name:MICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 VICTORY AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4823
Mailing Address - Country:US
Mailing Address - Phone:320-333-8226
Mailing Address - Fax:
Practice Address - Street 1:3250 W 66TH ST APT 548
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5514
Practice Address - Country:US
Practice Address - Phone:502-382-0927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5072133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered