Provider Demographics
NPI:1043413990
Name:GLENZ, LAURA EILEEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:EILEEN
Last Name:GLENZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535A W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3000
Mailing Address - Country:US
Mailing Address - Phone:516-432-3119
Mailing Address - Fax:
Practice Address - Street 1:535A W BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3000
Practice Address - Country:US
Practice Address - Phone:516-432-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005848-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9351E1Medicare ID - Type UnspecifiedPROVIDER #