Provider Demographics
NPI:1962830802
Name:ROSE, TERI LYNN (MS, LN)
Entity type:Individual
Prefix:MRS
First Name:TERI
Middle Name:LYNN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 W 43RD ST
Mailing Address - Street 2:STE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1696
Mailing Address - Country:US
Mailing Address - Phone:612-920-2822
Mailing Address - Fax:
Practice Address - Street 1:2822 W 43RD ST
Practice Address - Street 2:STE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1696
Practice Address - Country:US
Practice Address - Phone:612-920-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN196133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist