Provider Demographics
NPI:1679962625
Name:MALONE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MALONE
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 1:1715 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6608
Mailing Address - Country:US
Mailing Address - Phone:229-529-3437
Mailing Address - Fax:
Practice Address - Street 1:1715 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6608
Practice Address - Country:US
Practice Address - Phone:229-529-3437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002927133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered