Provider Demographics
NPI:1407139868
Name:FOG, RACHEL (RD, LD, CDCES)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:FOG
Suffix:
Gender:F
Credentials:RD, LD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 185TH CT NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MN
Mailing Address - Zip Code:55092-4402
Mailing Address - Country:US
Mailing Address - Phone:651-468-9207
Mailing Address - Fax:
Practice Address - Street 1:14001 RIDGEDALE DR STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1747
Practice Address - Country:US
Practice Address - Phone:952-249-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3087133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric