Provider Demographics
NPI:1063782340
Name:PECK, LARA K (RD CDE)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:K
Last Name:PECK
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:MS
Other - First Name:LARA
Other - Middle Name:K
Other - Last Name:BORDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD CDE
Mailing Address - Street 1:275 ROUTE 30 N
Mailing Address - Street 2:
Mailing Address - City:BOMOSEEN
Mailing Address - State:VT
Mailing Address - Zip Code:05732-9647
Mailing Address - Country:US
Mailing Address - Phone:802-468-5641
Mailing Address - Fax:802-468-2923
Practice Address - Street 1:275 ROUTE 30 N
Practice Address - Street 2:
Practice Address - City:BOMOSEEN
Practice Address - State:VT
Practice Address - Zip Code:05732-9647
Practice Address - Country:US
Practice Address - Phone:802-468-5641
Practice Address - Fax:802-468-2923
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT871969133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered