Provider Demographics
NPI:1689211526
Name:TULLBANE, ANGELA M (RD, LD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:TULLBANE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:16800 37TH PL N
Practice Address - Street 2:STE 100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:763-520-7580
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered