Provider Demographics
NPI:1871328898
Name:IGLESIA, ELISA (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:IGLESIA
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 KINGSVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4584
Mailing Address - Country:US
Mailing Address - Phone:612-805-5538
Mailing Address - Fax:
Practice Address - Street 1:3430 LIST PL APT 2202
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4573
Practice Address - Country:US
Practice Address - Phone:612-805-5538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered