Provider Demographics
NPI:1053011197
Name:MEYER, PHALEN (LN)
Entity type:Individual
Prefix:
First Name:PHALEN
Middle Name:
Last Name:MEYER
Suffix:
Gender:F
Credentials:LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:8675 VALLEY CREEK RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2337
Practice Address - Country:US
Practice Address - Phone:651-241-3000
Practice Address - Fax:651-241-3500
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN239133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNN239OtherLICENSE NUMBER