Provider Demographics
NPI:1245395144
Name:FORTIN, LAURA ANNA (RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANNA
Last Name:FORTIN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23723 119TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031
Mailing Address - Country:US
Mailing Address - Phone:253-631-1318
Mailing Address - Fax:
Practice Address - Street 1:3001 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4122
Practice Address - Country:US
Practice Address - Phone:206-205-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered