Provider Demographics
NPI:1174282396
Name:TANGUTURI, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:TANGUTURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:468 HAROLD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1740
Mailing Address - Country:US
Mailing Address - Phone:404-825-5074
Mailing Address - Fax:
Practice Address - Street 1:1341 CANTON RD STE B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6056
Practice Address - Country:US
Practice Address - Phone:980-296-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003877133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management