Provider Demographics
NPI:1568044998
Name:BAZYLER, LAURA (RD,LD/N)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BAZYLER
Suffix:
Gender:F
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 MONUMENT RD STE 33
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2771 MONUMENT RD STE 33
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3524
Practice Address - Country:US
Practice Address - Phone:904-450-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL702261133V00000X
FLND1200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered