Provider Demographics
NPI:1639611015
Name:WULLSCHLEGER, LAURA CHRISTINE (RDN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:WULLSCHLEGER
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 1:1498 SE TECH CENTER PL STE 240
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5508
Mailing Address - Country:US
Mailing Address - Phone:360-597-1313
Mailing Address - Fax:
Practice Address - Street 1:12123 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8514
Practice Address - Country:US
Practice Address - Phone:971-708-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10208267133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86056281OtherCOMMISSION ON DIETETIC REGISTRATION REGISTRATION ID NUMBER