Provider Demographics
NPI:1184833170
Name:DOLEZAL, LAURA LEAH (RD, LDN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEAH
Last Name:DOLEZAL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N OAKLEY BLVD APT 305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2229
Mailing Address - Country:US
Mailing Address - Phone:708-421-3029
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6493
Practice Address - Fax:312-569-6118
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003759133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered