Provider Demographics
NPI:1366940850
Name:GRAHAM, ELISE (RD, LD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:ELISE
Other - Middle Name:CORRIN
Other - Last Name:ADAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-848-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3576OtherBOARD OF DIETETICS & NUTRITION PRACTIVE
86044492OtherCOMMISSION ON DIETETIC REGISTRATION