Provider Demographics
NPI:1437238482
Name:OLSEN, LAURA (MNT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DICTUM CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5938
Mailing Address - Country:US
Mailing Address - Phone:718-769-8820
Mailing Address - Fax:718-769-8558
Practice Address - Street 1:2726 GERRITSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5915
Practice Address - Country:US
Practice Address - Phone:718-769-8820
Practice Address - Fax:718-769-8558
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000212-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYO3P291Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPI