Provider Demographics
NPI:1306887393
Name:WILLIE, MARYA DAWN (LRD)
Entity type:Individual
Prefix:
First Name:MARYA
Middle Name:DAWN
Last Name:WILLIE
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:MARYA
Other - Middle Name:D
Other - Last Name:KADOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:400 EAST THIRD STREET
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55800-1951
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2857
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:ESSENTIA HEALTH PARK RAPIDS CLINIC
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2857
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2280133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN34871OtherLHS/BANNERHEALTH #
MN6300246OtherMEDICA #
MN6300248OtherMEDICA #
MN6300247OtherMEDICA #
MNHP39460OtherHEALTHPARTNERS #
MN23627OtherNDBS #