Provider Demographics
NPI:1912388067
Name:VASKE, MARCIE MICHELLE
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:MICHELLE
Last Name:VASKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 LYNDALE AVE S STE 500
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2691
Mailing Address - Country:US
Mailing Address - Phone:612-419-9626
Mailing Address - Fax:
Practice Address - Street 1:2392 HARVEST WAY
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8444
Practice Address - Country:US
Practice Address - Phone:612-419-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN220133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education