Provider Demographics
NPI:1114762465
Name:WILD, LAURA KATHLEEN (BCHN)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:KATHLEEN
Last Name:WILD
Suffix:
Gender:F
Credentials:BCHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 RONDA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-4644
Mailing Address - Country:US
Mailing Address - Phone:213-373-4994
Mailing Address - Fax:
Practice Address - Street 1:2316 RONDA VISTA DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-4644
Practice Address - Country:US
Practice Address - Phone:213-373-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach