Provider Demographics
NPI:1821220732
Name:SHRADER, LAURIE M
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:SHRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:ELLEN
Other - Last Name:MAYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 N BANCROFT PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2690
Mailing Address - Country:US
Mailing Address - Phone:302-652-2455
Mailing Address - Fax:302-652-2444
Practice Address - Street 1:1020 FORREST AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-2799
Practice Address - Country:US
Practice Address - Phone:302-678-4622
Practice Address - Fax:302-678-2292
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0000258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered