Provider Demographics
NPI:1316482649
Name:MYDELS, SONJA (RD)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:MYDELS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4111
Mailing Address - Country:US
Mailing Address - Phone:612-458-9292
Mailing Address - Fax:
Practice Address - Street 1:2800 CLEVELAND AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1126
Practice Address - Country:US
Practice Address - Phone:651-789-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3805133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1562OtherCOLLEGE OF DIETITIANS OF BRITISH COLUMBIA