Provider Demographics
NPI:1720620321
Name:WILSON, LAURA LEE (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:WILSON
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 1:1427 OLD ORCHARD LOOP
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-3618
Mailing Address - Country:US
Mailing Address - Phone:434-660-1659
Mailing Address - Fax:
Practice Address - Street 1:118 HAMBY RD
Practice Address - Street 2:
Practice Address - City:DOBSON
Practice Address - State:NC
Practice Address - Zip Code:27017-8471
Practice Address - Country:US
Practice Address - Phone:336-401-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered