Provider Demographics
NPI:1659845014
Name:JANKOWSKI, MATTIE ROSE (RDN)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:ROSE
Last Name:JANKOWSKI
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1737
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:
Practice Address - Street 1:576 BIELENBERG DR STE 250
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1739
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered