Provider Demographics
NPI:1790051316
Name:REZNIK, ANDREA (RD LD)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:REZNIK
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 1:5327 BEACHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4113
Mailing Address - Country:US
Mailing Address - Phone:952-935-4135
Mailing Address - Fax:
Practice Address - Street 1:5327 BEACHSIDE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-4113
Practice Address - Country:US
Practice Address - Phone:952-935-4135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered