Provider Demographics
NPI:1770968240
Name:FULLER, LAURA MARIE (MS,RDN,LD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS,RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 N MCCLEARY RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-8490
Mailing Address - Country:US
Mailing Address - Phone:816-922-2411
Mailing Address - Fax:816-922-4644
Practice Address - Street 1:197 N MCCLEARY RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-8490
Practice Address - Country:US
Practice Address - Phone:816-922-2411
Practice Address - Fax:816-922-4644
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001026126133V00000X
KS1859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered