Healthcare Provider Details

I. General information

NPI: 1639611015
Provider Name (Legal Business Name): LAURA CHRISTINE WULLSCHLEGER RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12123 SW 69TH AVE
PORTLAND OR
97223-8514
US

IV. Provider business mailing address

1498 SE TECH CENTER PL STE 240
VANCOUVER WA
98683-5508
US

V. Phone/Fax

Practice location:
  • Phone: 971-708-7600
  • Fax:
Mailing address:
  • Phone: 360-597-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10208267
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: