Provider Demographics
NPI:1801346879
Name:FETZER, LAUREL LYNNE (RD)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:LYNNE
Last Name:FETZER
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 1:4727 S RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3811
Mailing Address - Country:US
Mailing Address - Phone:801-414-9336
Mailing Address - Fax:
Practice Address - Street 1:4727 S RAINBOW DR
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3811
Practice Address - Country:US
Practice Address - Phone:801-414-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9266996-4901136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered