Individual
MARY MAUREEN BAZILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD
Contact information
Practice address
2450 RIVERSIDE AVE, MINNEAPOLIS, MN 55454-1450
(612) 273-4395
Mailing address
2450 RIVERSIDE AVE, MINNEAPOLIS, MN 55454-1450
(612) 273-4395
Taxonomy
Speciality
Code
Description
License number
State
133N00000X
Nutritionist
Primary
994556
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004909976
—
VA
Enumeration date
07/30/2008
Last updated
12/28/2010
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