Provider Demographics
NPI:1942468640
Name:BOSAK, LAURIE ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:BOSAK
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 1:5005 MANTA CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4244
Mailing Address - Country:US
Mailing Address - Phone:301-645-4641
Mailing Address - Fax:
Practice Address - Street 1:5005 MANTA CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4244
Practice Address - Country:US
Practice Address - Phone:301-645-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2417133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered