Provider Demographics
NPI:1376611145
Name:SCHWANENBERGER, LAURIE A (RD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:SCHWANENBERGER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N. FORBES BLVD.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745
Mailing Address - Country:US
Mailing Address - Phone:520-872-7265
Mailing Address - Fax:520-872-7929
Practice Address - Street 1:6567 E CARONDELET DR STE 555
Practice Address - Street 2:CARONDELET MEDICAL GROUP
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-885-3588
Practice Address - Fax:520-290-3958
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ804775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162704Medicaid
AZ162704Medicaid