Provider Demographics
NPI:1972090611
Name:PINNICK, LAURA CHRISTINE (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:PINNICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:CHRISTINE
Other - Last Name:FANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:321 E MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4731
Mailing Address - Country:US
Mailing Address - Phone:406-924-9396
Mailing Address - Fax:844-895-9037
Practice Address - Street 1:321 E MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-924-9396
Practice Address - Fax:844-895-9037
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1972090611Medicaid