Provider Demographics
NPI:1801571708
Name:MCCONACHIE, AMELIA LEVAKE (RD)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:LEVAKE
Last Name:MCCONACHIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:LEVAKE
Other - Last Name:ROSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:5642 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5337
Mailing Address - Country:US
Mailing Address - Phone:218-310-5943
Mailing Address - Fax:
Practice Address - Street 1:5642 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5337
Practice Address - Country:US
Practice Address - Phone:218-310-5943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
975536133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered