Provider Demographics
NPI:1093178394
Name:MCBRIDE, LAURIE NICOLE (RD, LD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:NICOLE
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:NICOLE
Other - Last Name:BYRNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 205
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-0945
Practice Address - Fax:208-415-0150
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1093178394Medicaid