Provider Demographics
NPI:1740977362
Name:MACK, VANESSA (RD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MACK
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 1:46114 506TH ST
Mailing Address - Street 2:
Mailing Address - City:NICOLLET
Mailing Address - State:MN
Mailing Address - Zip Code:56074-4003
Mailing Address - Country:US
Mailing Address - Phone:507-276-1463
Mailing Address - Fax:
Practice Address - Street 1:46114 506TH ST
Practice Address - Street 2:
Practice Address - City:NICOLLET
Practice Address - State:MN
Practice Address - Zip Code:56074-4003
Practice Address - Country:US
Practice Address - Phone:507-276-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1040868133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered