Provider Demographics
NPI:1124086244
Name:HAGENBUCH, REBECCA EDNA (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:EDNA
Last Name:HAGENBUCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:EDNA
Other - Last Name:KOEHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-626-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered