MEDICARE: LISA M. LAURA R.D., LDN, J.D.

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	133V00000X	Registered Dietitian	DN004576	PA

General Provider Information

NPI Number	:	1497037980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M. LAURA R.D., LDN, J.D.

Provider Business Mailing Address
First Line	:	101 GREENWOOD AVE
Second Line	:	SUITE 410
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-2627
Country	:	US
Telephone Number	:	267-240-4260
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 GREENWOOD AVE
Second Line	:	SUITE 410
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-2627
Country	:	US
Telephone Number	:	267-240-4260
Fax Number	:

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

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	09/12/2011

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