Healthcare Provider Details

I. General information

NPI: 1154394567
Provider Name (Legal Business Name): LAURIE JEANNE STRUTHERS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LATHROP STREET SUITE 122
FAIRBANKS AK
99701
US

IV. Provider business mailing address

1319 3RD AVE
FAIRBANKS AK
99701
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-6400
  • Fax: 907-458-6405
Mailing address:
  • Phone: 907-458-5639
  • Fax: 907-458-5693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number42
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: