Healthcare Provider Details

I. General information

NPI: 1437238482
Provider Name (Legal Business Name): LAURA OLSEN MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2726 GERRITSEN AVE
BROOKLYN NY
11229-5915
US

IV. Provider business mailing address

20 DICTUM CT
BROOKLYN NY
11229-5938
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-8820
  • Fax: 718-769-8558
Mailing address:
  • Phone: 718-769-8820
  • Fax: 718-769-8558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000212-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: