Provider Demographics
NPI:1861031254
Name:PRESTIGIACOMO, PAIGE (RD)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:PRESTIGIACOMO
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 1:715 WESTON RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1202
Mailing Address - Country:US
Mailing Address - Phone:608-692-2147
Mailing Address - Fax:
Practice Address - Street 1:715 WESTON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1202
Practice Address - Country:US
Practice Address - Phone:608-692-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4248133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered