Provider Demographics
NPI:1821594656
Name:KNAEBE, BRONWYN LISSA (RD)
Entity Type:Individual
Prefix:
First Name:BRONWYN
Middle Name:LISSA
Last Name:KNAEBE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 TOWN CENTRE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1186
Mailing Address - Country:US
Mailing Address - Phone:651-379-1600
Mailing Address - Fax:
Practice Address - Street 1:1185 TOWN CENTRE DR STE 220
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1186
Practice Address - Country:US
Practice Address - Phone:651-379-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3968133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic