Provider Demographics
NPI:1518522812
Name:GANGESTAD, TINA MARIE (RDN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GANGESTAD
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 COUNTY ROAD 130
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-1433
Mailing Address - Country:US
Mailing Address - Phone:218-330-5606
Mailing Address - Fax:
Practice Address - Street 1:3508 COUNTY ROAD 130
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-1433
Practice Address - Country:US
Practice Address - Phone:218-330-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3395133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered