Provider Demographics
NPI:1437216603
Name:KOLLER, LAURA MARIA (CDE)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIA
Last Name:KOLLER
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:9977 WOODS DR
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1057
Practice Address - Country:US
Practice Address - Phone:847-663-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic