Provider Demographics
NPI:1538474515
Name:PATTERSON, LAURIE B (RD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:B
Last Name:PATTERSON
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 1:1234 E. DUPONT RD
Mailing Address - Street 2:STE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:2200 RANDALLIA DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-373-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000673900OtherANTHEM
IN000000673897OtherANTHEM
IN000000673900OtherANTHEM
INM400024539Medicare PIN