Basic Information
| Provider Information | |||||||||
| NPI: | 1821220732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRADER | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | M | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYAN | ||||||||
| OtherFirstName: | LAURIE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1010 N BANCROFT PKWY | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198052690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026522455 | ||||||||
| FaxNumber: | 3026522444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 FORREST AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199042799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026784622 | ||||||||
| FaxNumber: | 3026782292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 03/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN-0000258 | DE | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.