Healthcare Provider Details

I. General information

NPI: 1245395144
Provider Name (Legal Business Name): LAURA ANNA FORTIN R.D., C.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 NE 4TH ST
RENTON WA
98056-4122
US

IV. Provider business mailing address

23723 119TH PL SE
KENT WA
98031
US

V. Phone/Fax

Practice location:
  • Phone: 206-205-1674
  • Fax:
Mailing address:
  • Phone: 253-631-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001904
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: