Provider Demographics
NPI:1700569688
Name:WALTERS, TEAL MARIE (RDN, LD)
Entity type:Individual
Prefix:
First Name:TEAL
Middle Name:MARIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7350 BRISTOL VILLAGE DR APT 321
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2587
Mailing Address - Country:US
Mailing Address - Phone:612-367-6257
Mailing Address - Fax:
Practice Address - Street 1:3808 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1304
Practice Address - Country:US
Practice Address - Phone:612-367-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4818133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered