Provider Demographics
NPI:1396114328
Name:VANDER LAAN, ELIZABETH J (MS, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:J
Last Name:VANDER LAAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9847 YALTA ST NE
Mailing Address - Street 2:
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-2511
Mailing Address - Country:US
Mailing Address - Phone:763-783-7321
Mailing Address - Fax:
Practice Address - Street 1:913 E 26TH ST STE 401
Practice Address - Street 2:MR 39401
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4515
Practice Address - Country:US
Practice Address - Phone:612-863-7622
Practice Address - Fax:612-863-8900
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered