Provider Demographics
NPI:1689135212
Name:MERCADO, LAURA RENEE (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:RENEE
Last Name:MERCADO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18002 RICHMOND PLACE DR APT 3316
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1737
Mailing Address - Country:US
Mailing Address - Phone:813-777-5942
Mailing Address - Fax:
Practice Address - Street 1:4700 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7160
Practice Address - Country:US
Practice Address - Phone:813-777-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7608133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered