Provider Demographics
NPI:1740952050
Name:BAREM, MIKALAH A (RDN)
Entity type:Individual
Prefix:
First Name:MIKALAH
Middle Name:A
Last Name:BAREM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 BANDANA BLVD
Mailing Address - Street 2:W STE 210
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:844-358-8786
Practice Address - Street 1:2020 E 29TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3948
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:509-252-1367
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61197617390200000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program