Provider Demographics
NPI:1295847606
Name:SELBY, LAURA MARIE (RDN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:SELBY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63627-9136
Mailing Address - Country:US
Mailing Address - Phone:573-702-8089
Mailing Address - Fax:
Practice Address - Street 1:37 MEYER LN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9138
Practice Address - Country:US
Practice Address - Phone:573-483-3734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004289133V00000X
MO2015021390133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164004289OtherLICENSE