Provider Demographics
NPI:1073154167
Name:SAMUEL, LAUREN KAYE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:KAYE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1274
Mailing Address - Country:US
Mailing Address - Phone:419-307-7879
Mailing Address - Fax:419-520-9314
Practice Address - Street 1:228 N LAWN AVE
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1274
Practice Address - Country:US
Practice Address - Phone:419-307-7879
Practice Address - Fax:419-520-9314
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.08539133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered