Healthcare Provider Details

I. General information

NPI: 1689828949
Provider Name (Legal Business Name): LAURA DYCK MSRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W STONE DR STE 310
KINGSPORT TN
37660-6030
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-398-7024
  • Fax: 423-398-7031
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLDN0000001303
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000001303
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: