Basic Information
| Provider Information | |||||||||
| NPI: | 1164081865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | WALKER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043845043 | ||||||||
| FaxNumber: | 7043848895 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 QUEENS RD STE 330 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043845043 | ||||||||
| FaxNumber: | 7043848895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2019 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L004924 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.