Provider Demographics
NPI:1134654213
Name:SHORES, LAURA (RD, LD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SHORES
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-2023
Practice Address - Street 1:705 HIGHWAY 63 N
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:AR
Practice Address - Zip Code:72064
Practice Address - Country:US
Practice Address - Phone:870-255-3696
Practice Address - Fax:870-255-4061
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1331133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered