Provider Demographics
NPI:1144481037
Name:ASHLEY, LAURA SANDRA (LICENSED DIETITIAN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SANDRA
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W 45TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-3014
Mailing Address - Country:US
Mailing Address - Phone:512-451-5800
Mailing Address - Fax:512-459-1399
Practice Address - Street 1:408 W 45TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-3014
Practice Address - Country:US
Practice Address - Phone:512-451-5800
Practice Address - Fax:512-459-1399
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06727133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198066602Medicaid
TX198066602Medicaid