Provider Demographics
NPI:1154364602
Name:DRISCOLL, REBECCA A (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1670 ROBERT ST S # 129
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3918
Mailing Address - Country:US
Mailing Address - Phone:651-276-8018
Mailing Address - Fax:
Practice Address - Street 1:21 DORSET RD
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-1914
Practice Address - Country:US
Practice Address - Phone:651-276-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1983133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered