Healthcare Provider Details

I. General information

NPI: 1205278652
Provider Name (Legal Business Name): AUDREY LAURELTON R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 BLOOMFIELD AVE SUITE 406
MONTCLAIR NJ
07042-3583
US

IV. Provider business mailing address

427 BLOOMFIELD AVE SUITE 406
MONTCLAIR NJ
07042-3583
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-3555
  • Fax:
Mailing address:
  • Phone: 973-744-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: