Provider Demographics
NPI:1003459280
Name:SIMMONS, LAURA GRACE (MS, RDN, CD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:STE 3A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-450-9474
Mailing Address - Fax:425-452-0704
Practice Address - Street 1:1620 LAKE TAPPS PKWY SE STE 115
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-8376
Practice Address - Country:US
Practice Address - Phone:253-939-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86119587133V00000X
MO2019039025133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61078483OtherWA STATE DOH