Provider Demographics
NPI:1912059486
Name:BROOKS, LAURA LEE (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:BROOKS
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 1:1019 PACIFIC AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4443
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:253-722-1546
Practice Address - Street 1:1708 E 44TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4611
Practice Address - Country:US
Practice Address - Phone:253-471-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8384034Medicaid
Q11177Medicare UPIN
8801914Medicare ID - Type Unspecified