Healthcare Provider Details

I. General information

NPI: 1558920637
Provider Name (Legal Business Name): LAURIE MCDONALD NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13842 S 32ND ST
PHOENIX AZ
85044-3615
US

IV. Provider business mailing address

13842 S 32ND ST
PHOENIX AZ
85044-3615
US

V. Phone/Fax

Practice location:
  • Phone: 602-770-8924
  • Fax:
Mailing address:
  • Phone: 602-770-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: LAURIE BRADLEY MCDONALD
Title or Position: OWNER
Credential: RDN
Phone: 602-770-8924