Provider Demographics
NPI:1558861831
Name:MOULTON, LAURA JEAN (RDN)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JEAN
Last Name:MOULTON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-0425
Mailing Address - Country:US
Mailing Address - Phone:208-590-0858
Mailing Address - Fax:
Practice Address - Street 1:285 E 4TH N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2716
Practice Address - Country:US
Practice Address - Phone:208-590-0858
Practice Address - Fax:855-740-2997
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-039133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered