Provider Demographics
NPI:1669164703
Name:LLAURY-MARKS, JOANNE
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:LLAURY-MARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:JENSEN
Mailing Address - State:UT
Mailing Address - Zip Code:84035-0480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9235 S REDWASH RD
Practice Address - Street 2:
Practice Address - City:JENSEN
Practice Address - State:UT
Practice Address - Zip Code:84035-9745
Practice Address - Country:US
Practice Address - Phone:303-621-6948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X
WANU6151602133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty