MEDICARE: MS. LAURA KATHLEEN WILD BCHN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach
2	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1114762465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA KATHLEEN WILD BCHN

Provider Business Mailing Address
First Line	:	2316 RONDA VISTA DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-4644
Country	:	US
Telephone Number	:	213-373-4994
Fax Number	:

Provider Business Practice Location Address
First Line	:	2316 RONDA VISTA DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-4644
Country	:	US
Telephone Number	:	213-373-4994
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	06/27/2024

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