Healthcare Provider Details

I. General information

NPI: 1881421543
Provider Name (Legal Business Name): LAURA SOUDANT CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 GREENVILLE TPKE
PORT JERVIS NY
12771-3253
US

IV. Provider business mailing address

1684 GREENVILLE TPKE
PORT JERVIS NY
12771-3253
US

V. Phone/Fax

Practice location:
  • Phone: 845-590-7926
  • Fax:
Mailing address:
  • Phone: 845-590-7926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDN009272
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: