Basic Information
| Provider Information | |||||||||
| NPI: | 1528212560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172693907 | ||||||||
| FaxNumber: | 4172698260 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172693907 | ||||||||
| FaxNumber: | 4172698260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 11/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2008021812 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.