Healthcare Provider Details

I. General information

NPI: 1417509159
Provider Name (Legal Business Name): LAURA BAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 FAST PARK DR STE 211
RALEIGH NC
27617-4853
US

IV. Provider business mailing address

1005 W MAIN ST APT 142
DURHAM NC
27701-1363
US

V. Phone/Fax

Practice location:
  • Phone: 919-442-8398
  • Fax:
Mailing address:
  • Phone: 919-698-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL005791
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: