Provider Demographics
NPI:1669246393
Name:WARD, LAURA SUSANNE (RD, IBCLC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSANNE
Last Name:WARD
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 MOHAWK CLIFF RD
Mailing Address - Street 2:
Mailing Address - City:OHATCHEE
Mailing Address - State:AL
Mailing Address - Zip Code:36271-4410
Mailing Address - Country:US
Mailing Address - Phone:706-580-6551
Mailing Address - Fax:
Practice Address - Street 1:1121 MOHAWK CLIFF RD
Practice Address - Street 2:
Practice Address - City:OHATCHEE
Practice Address - State:AL
Practice Address - Zip Code:36271-4410
Practice Address - Country:US
Practice Address - Phone:706-580-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL86006705133V00000X
ALL-104679174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN