Healthcare Provider Details

I. General information

NPI: 1558855171
Provider Name (Legal Business Name): LAURA ELIZABETH HENDERSON CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 ROLAND AVE APT 2F
BALTIMORE MD
21211-2004
US

IV. Provider business mailing address

3801 ROLAND AVE APT 2F
BALTIMORE MD
21211-2004
US

V. Phone/Fax

Practice location:
  • Phone: 724-549-4900
  • Fax:
Mailing address:
  • Phone: 724-549-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4319
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: