Provider Demographics
NPI:1528822624
Name:NOURISHING WAVES NUTRITION PLLC
Entity type:Organization
Organization Name:NOURISHING WAVES NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:952-358-1414
Mailing Address - Street 1:4145 42ND AVE S UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2124 DUPONT AVE S STE 202
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2719
Practice Address - Country:US
Practice Address - Phone:952-358-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered