Basic Information
Provider Information | |||||||||
NPI: | 1306887393 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIE | ||||||||
FirstName: | MARYA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LRD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KADOW | ||||||||
OtherFirstName: | MARYA | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LRD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 400 EAST THIRD STREET | ||||||||
Address2: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558001951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187322800 | ||||||||
FaxNumber: | 2187322857 | ||||||||
Practice Location | |||||||||
Address1: | 705 PLEASANT AVE S | ||||||||
Address2: | ESSENTIA HEALTH PARK RAPIDS CLINIC | ||||||||
City: | PARK RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 564701440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187322800 | ||||||||
FaxNumber: | 2187322857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 03/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2280 | MN | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 34871 | 01 | MN | LHS/BANNERHEALTH # | OTHER | 6300246 | 01 | MN | MEDICA # | OTHER | 6300248 | 01 | MN | MEDICA # | OTHER | 6300247 | 01 | MN | MEDICA # | OTHER | HP39460 | 01 | MN | HEALTHPARTNERS # | OTHER | 23627 | 01 | MN | NDBS # | OTHER |