Healthcare Provider Details

I. General information

NPI: 1376053918
Provider Name (Legal Business Name): LAURA ELIZABETH BRUNERO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 PILGRIM AVE
COVENTRY RI
02816-4215
US

IV. Provider business mailing address

144 PILGRIM AVE
COVENTRY RI
02816-4215
US

V. Phone/Fax

Practice location:
  • Phone: 401-787-4022
  • Fax: 401-244-7272
Mailing address:
  • Phone: 401-787-4022
  • Fax: 401-244-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86042672
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: