Provider Demographics
NPI:1295061026
Name:REYNOSO, CARRIE M (RD, LD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:M
Last Name:REYNOSO
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 1:14500 99TH AVE N # THAVEN
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4730
Mailing Address - Country:US
Mailing Address - Phone:763-898-1000
Mailing Address - Fax:
Practice Address - Street 1:14500 99TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4730
Practice Address - Country:US
Practice Address - Phone:763-898-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered