Provider Demographics
NPI:1417509159
Name:BAUM, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W MAIN ST APT 142
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1363
Mailing Address - Country:US
Mailing Address - Phone:919-698-7759
Mailing Address - Fax:
Practice Address - Street 1:8801 FAST PARK DR STE 211
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4853
Practice Address - Country:US
Practice Address - Phone:919-442-8398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005791133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist