Provider Demographics
NPI:1821109422
Name:LOVE, MARLA RAE (LRD)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:RAE
Last Name:LOVE
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:RAE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716
Mailing Address - Country:US
Mailing Address - Phone:218-281-9100
Mailing Address - Fax:218-281-9189
Practice Address - Street 1:400 S MINNESOTA STREET
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716
Practice Address - Country:US
Practice Address - Phone:218-281-9100
Practice Address - Fax:218-281-9189
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
ND432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN23623Medicare ID - Type Unspecified