Basic Information
| Provider Information | |||||||||
| NPI: | 1124406848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD,LD,CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | 21320325 | MN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 136A00000X | 2330 | MN | Y | Dietary & Nutritional Service Providers | Dietetic Technician, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2330 | 01 | MN | BOARD OF DIETETICS | OTHER | 21320325 | 01 | MN | DIABETES EDUCATORS | OTHER |