Provider Demographics
NPI:1063891364
Name:WEBER, LAURA ANN (MSED, RD, IBCLC)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANN
Last Name:WEBER
Suffix:
Gender:F
Credentials:MSED, RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1622
Mailing Address - Country:US
Mailing Address - Phone:314-799-3851
Mailing Address - Fax:
Practice Address - Street 1:8110 E RITA DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-5406
Practice Address - Country:US
Practice Address - Phone:314-799-3851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL-47496174N00000X
MOL-47496174N00000X
MO2017011597133V00000X
AZ893600133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN