Healthcare Provider Details

I. General information

NPI: 1174282396
Provider Name (Legal Business Name): LAURA TANGUTURI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 CANTON RD STE B
MARIETTA GA
30066-6056
US

IV. Provider business mailing address

468 HAROLD AVE NE
ATLANTA GA
30307-1740
US

V. Phone/Fax

Practice location:
  • Phone: 980-296-0044
  • Fax:
Mailing address:
  • Phone: 404-825-5074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLD003877
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: