Provider Demographics
NPI:1538711213
Name:NYBERG, ELLISA (MS, RDN, LN, LD)
Entity type:Individual
Prefix:
First Name:ELLISA
Middle Name:
Last Name:NYBERG
Suffix:
Gender:F
Credentials:MS, RDN, LN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 N DUBUQUE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-6402
Mailing Address - Country:US
Mailing Address - Phone:605-359-1065
Mailing Address - Fax:
Practice Address - Street 1:1417 N DUBUQUE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-6402
Practice Address - Country:US
Practice Address - Phone:605-359-1065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2298133V00000X
SD0219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD11282001Medicaid
SD11282001OtherUMR