Provider Demographics
NPI:1558550459
Name:EAGLE, LOURAINE
Entity Type:Individual
Prefix:MRS
First Name:LOURAINE
Middle Name:
Last Name:EAGLE
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 1:769 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1198
Mailing Address - Country:US
Mailing Address - Phone:973-731-6565
Mailing Address - Fax:973-731-9855
Practice Address - Street 1:769 NORTHFIELD AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1198
Practice Address - Country:US
Practice Address - Phone:973-731-6565
Practice Address - Fax:973-731-9855
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0584681OtherCIGNA
NJP2951858OtherOXFORD
NJ2234854OtherUNITED HEALTHCARE
NJ2959549OtherAETNA
NJP2951858OtherOXFORD
NJ072646Medicare PIN