Healthcare Provider Details

I. General information

NPI: 1659973311
Provider Name (Legal Business Name): LAURA CATHERINE DZIUBYK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2190 S LAKE ST APT 11
SALT LAKE CITY UT
84106-5807
US

IV. Provider business mailing address

2190 S LAKE ST APT 11
SALT LAKE CITY UT
84106-5807
US

V. Phone/Fax

Practice location:
  • Phone: 847-431-8294
  • Fax:
Mailing address:
  • Phone: 847-431-8294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37003245A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09320
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number273436
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number12466857-4901
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164011701
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: