Provider Demographics
NPI:1790976512
Name:ROSALES, LAURA M (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:ROSALES
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8443
Mailing Address - Country:US
Mailing Address - Phone:575-532-8900
Mailing Address - Fax:575-532-8910
Practice Address - Street 1:4371 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8443
Practice Address - Country:US
Practice Address - Phone:575-532-8900
Practice Address - Fax:575-532-8910
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06119133V00000X
NMLD0748133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered