Provider Demographics
NPI:1295089068
Name:LINDELL DETWEILER, CHRISTINE JOY (RD, MPH)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:JOY
Last Name:LINDELL DETWEILER
Suffix:
Gender:F
Credentials:RD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 41ST AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3419
Mailing Address - Country:US
Mailing Address - Phone:763-222-5598
Mailing Address - Fax:720-293-5560
Practice Address - Street 1:4055 41ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3419
Practice Address - Country:US
Practice Address - Phone:763-222-5598
Practice Address - Fax:720-293-5560
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3122133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered