Provider Demographics
NPI:1427298926
Name:OMIDVARAN, LAURA AUDREY (RD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:AUDREY
Last Name:OMIDVARAN
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 1:4512 SNOWFLAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4287
Mailing Address - Country:US
Mailing Address - Phone:505-897-9791
Mailing Address - Fax:
Practice Address - Street 1:10501 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5019
Practice Address - Country:US
Practice Address - Phone:505-727-2369
Practice Address - Fax:505-727-2291
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered