Provider Demographics
NPI:1174750574
Name:CAMPBELL, LAURA ANNE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8224 WETHERILL CIR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-3635
Mailing Address - Country:US
Mailing Address - Phone:303-688-2940
Mailing Address - Fax:
Practice Address - Street 1:8224 WETHERILL CIR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-3635
Practice Address - Country:US
Practice Address - Phone:303-688-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0717133V00000X
CO708961133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered