Provider Demographics
NPI:1689828949
Name:DYCK, LAURA (MSRD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DYCK
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W STONE DR STE 310
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6030
Mailing Address - Country:US
Mailing Address - Phone:423-398-7024
Mailing Address - Fax:423-398-7031
Practice Address - Street 1:111 W STONE DR STE 310
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6030
Practice Address - Country:US
Practice Address - Phone:423-398-7024
Practice Address - Fax:423-398-7031
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001303133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education