Provider Demographics
NPI:1194931113
Name:CORUM, AMY SUE (RD, LD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:CORUM
Suffix:
Gender:F
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 1:15630 UPPER 194TH ST E
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-9685
Mailing Address - Country:US
Mailing Address - Phone:651-438-3348
Mailing Address - Fax:
Practice Address - Street 1:1175 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1056
Practice Address - Country:US
Practice Address - Phone:651-480-4100
Practice Address - Fax:651-480-4212
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered