Provider Demographics
NPI:1689078834
Name:ELLEFSON, KATHERINE J (RD,CD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:J
Last Name:ELLEFSON
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DRESSER
Mailing Address - State:WI
Mailing Address - Zip Code:54009-4203
Mailing Address - Country:US
Mailing Address - Phone:715-417-1705
Mailing Address - Fax:
Practice Address - Street 1:6625 LYNDALE AVE S STE 430
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2300
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2694-29133V00000X
MN3236133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1055136OtherCOMMISSION ON DIETETIC REGISTRATION