Healthcare Provider Details

I. General information

NPI: 1265607360
Provider Name (Legal Business Name): LAURA PHILLIPS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E INDUSTRIAL DR
WASILLA AK
99654-8201
US

IV. Provider business mailing address

2000 E INDUSTRIAL DR
WASILLA AK
99654-8201
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-3003
  • Fax: 907-357-3003
Mailing address:
  • Phone: 907-357-3003
  • Fax: 907-357-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number102
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: