Provider Demographics
NPI:1063177335
Name:BOLLINGER, LAURA (RD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOLLINGER
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 1:2310 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9732
Mailing Address - Country:US
Mailing Address - Phone:260-336-1415
Mailing Address - Fax:
Practice Address - Street 1:2310 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9732
Practice Address - Country:US
Practice Address - Phone:260-336-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1057633133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered