Provider Demographics
NPI:1801300793
Name:MAHONEY, LAURA KATHLEEN (MS, RDN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W 9TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8932
Mailing Address - Country:US
Mailing Address - Phone:617-823-4975
Mailing Address - Fax:
Practice Address - Street 1:12 W 9TH ST APT 4B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8932
Practice Address - Country:US
Practice Address - Phone:617-823-4975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008567133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered