Healthcare Provider Details

I. General information

NPI: 1184954539
Provider Name (Legal Business Name): LAURA LEIGH WOLOK R.D., C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4354
US

IV. Provider business mailing address

2740 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4354
US

V. Phone/Fax

Practice location:
  • Phone: 877-511-4625
  • Fax: 703-204-9006
Mailing address:
  • Phone: 877-511-4625
  • Fax: 703-204-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number20320510
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: