Provider Demographics
NPI:1962870675
Name:CANCEL, LAURA JEAN (RD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:CANCEL
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 1:173 BYERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-8788
Mailing Address - Country:US
Mailing Address - Phone:270-312-5650
Mailing Address - Fax:
Practice Address - Street 1:914 N DIXIE AVE STE 306
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2537
Practice Address - Country:US
Practice Address - Phone:270-769-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered