MEDICARE: MRS. LAURA DEANE MS, RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT80442	TX

General Provider Information

NPI Number	:	1134472145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA DEANE MS, RD, LD

Provider Business Mailing Address
First Line	:	6333 PINIONPARK WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-7751
Country	:	US
Telephone Number	:	817-995-9368
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 W MAGNOLIA AVE
Second Line	:	200
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4472
Country	:	US
Telephone Number	:	817-995-9368
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2012
Last Update Date	:	10/16/2012

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