Provider Demographics
NPI:1447844618
Name:LAWRENCE, ANDREA HARIET (RDN, LDN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:HARIET
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 REYNOLDA RD STE 5
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4606
Mailing Address - Country:US
Mailing Address - Phone:760-622-6936
Mailing Address - Fax:
Practice Address - Street 1:2422 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4606
Practice Address - Country:US
Practice Address - Phone:760-622-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86113290133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86113290OtherCOMMISSION ON DIETETIC REGISTRATION
NCL006250OtherNORTH CAROLINA BOARD OF DIETETICS/NUTRITION