Provider Demographics
NPI:1629668751
Name:KING, LAURA (LAC, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LAC, RDN, LDN
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, RDN, LDN
Mailing Address - Street 1:4112 BOTELER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-7308
Mailing Address - Country:US
Mailing Address - Phone:410-245-9584
Mailing Address - Fax:
Practice Address - Street 1:15948 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:MD
Practice Address - Zip Code:21797-8526
Practice Address - Country:US
Practice Address - Phone:240-221-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2518133V00000X
MDU02945171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered