Basic Information
| Provider Information | |||||||||
| NPI: | 1811311814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTZENBERGER | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 HAMLINE ST - ALTRU FAMILY MEDICINE RESIDENCY | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017806400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | R34242 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.