Provider Demographics
NPI:1215308747
Name:WANDELL, HAYLEY M (RD, LD)
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:M
Last Name:WANDELL
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 1:1449 CLEVELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1413
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-328-8254
Practice Address - Street 1:1449 CLEVELAND AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1413
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:651-328-8254
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3956133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered