Provider Demographics
NPI:1487367017
Name:THOR, MAYLY (RD, LD)
Entity type:Individual
Prefix:
First Name:MAYLY
Middle Name:
Last Name:THOR
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 PASCAL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3124
Mailing Address - Country:US
Mailing Address - Phone:612-247-8432
Mailing Address - Fax:
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 250
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2107
Practice Address - Country:US
Practice Address - Phone:763-299-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered