Provider Demographics
NPI:1063036820
Name:CROAKER, ELLIE LYNN (RD, LD)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:LYNN
Last Name:CROAKER
Suffix:
Gender:
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6782 LAKEVIEW CIR # A
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9798
Mailing Address - Country:US
Mailing Address - Phone:612-709-3491
Mailing Address - Fax:
Practice Address - Street 1:12161 63RD ST NE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4627
Practice Address - Country:US
Practice Address - Phone:612-709-3491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered