Healthcare Provider Details

I. General information

NPI: 1851908727
Provider Name (Legal Business Name): LAURA ELIZABETH DEAN RD, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST # 5A6B
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4940
  • Fax: 502-588-7712
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number913115
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number246261
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: