Provider Demographics
NPI:1073375887
Name:SEPULVEDA, LAURA PAOLA (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:PAOLA
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 BROCK ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3561
Mailing Address - Country:US
Mailing Address - Phone:956-890-9475
Mailing Address - Fax:
Practice Address - Street 1:2803 BROCK ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3561
Practice Address - Country:US
Practice Address - Phone:956-890-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered