Provider Demographics
NPI:1306345996
Name:MORTON, LAURA (RD, LDN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MORTON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6658 GOEDDELTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-2638
Mailing Address - Country:US
Mailing Address - Phone:618-401-2206
Mailing Address - Fax:
Practice Address - Street 1:6658 GOEDDELTOWN RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-2638
Practice Address - Country:US
Practice Address - Phone:618-401-2206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007067133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered