Provider Demographics
NPI:1407478274
Name:BANTLE, LAURA LOUISE SANFORD (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE SANFORD
Last Name:BANTLE
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 1:50 STANIFORD ST
Mailing Address - Street 2:STE 430
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2541
Mailing Address - Country:US
Mailing Address - Phone:617-726-2040
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST # A
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-983-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86082245133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered