1083650022 NPI number — MRS. LAURA TENGELSEN CRIST RD LDN

Table of content: MRS. LAURA TENGELSEN CRIST RD LDN (NPI 1083650022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083650022 NPI number — MRS. LAURA TENGELSEN CRIST RD LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRIST
Provider First Name:
LAURA
Provider Middle Name:
TENGELSEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TENGELSEN
Provider Other First Name:
LAURA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD LDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083650022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6849 OLD WATERLOO RD
Provider Second Line Business Mailing Address:
APT NO 1433
Provider Business Mailing Address City Name:
ELKRIDGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21075-7142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-273-8031
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4940 EASTERN AVENUE
Provider Second Line Business Practice Location Address:
JOHNS HOPKINS BAYVIEW MEDICAL CENTER CLINICAL NUTRITION
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224-2780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-550-1549
Provider Business Practice Location Address Fax Number:
410-550-0650
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  PX2556 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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