Provider Demographics
NPI:1336010792
Name:KNUTSON, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KNUTSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 NORTHDALE BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-6713
Mailing Address - Country:US
Mailing Address - Phone:763-210-2608
Mailing Address - Fax:
Practice Address - Street 1:14800 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4520
Practice Address - Country:US
Practice Address - Phone:952-777-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management