Provider Demographics
NPI:1154198802
Name:TETLIE, RACHEL RICE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:RICE
Last Name:TETLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 43 1/2 AVE NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3021
Mailing Address - Country:US
Mailing Address - Phone:651-402-3882
Mailing Address - Fax:
Practice Address - Street 1:1500 CENTRAL PARK COMMONS DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-8702
Practice Address - Country:US
Practice Address - Phone:515-267-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4655133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered