Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4153 | MN |
NPI | 1477680379 |
---|---|
Provider Name | Mrs. Tara Lyn Roman |
First Address | Elko, MN 55020-8504 |
Second Address | Prior Lake, MN 55372-1770 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 08/07/2007 |