Basic Information
| Provider Information | |||||||||
| NPI: | 1003459280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | MS, RDN, CD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11711 NE 12TH ST | ||||||||
| Address2: | STE 3A | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 LAKE TAPPS PKWY SE STE 115 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980928376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539397179 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2019 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86119587 | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2019039025 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 61078483 | 01 | WA | WA STATE DOH | OTHER |