Provider Demographics
NPI:1073987806
Name:LAZAR, SHANE ERICA (RDN)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ERICA
Last Name:LAZAR
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3454
Mailing Address - Country:US
Mailing Address - Phone:978-884-7696
Mailing Address - Fax:
Practice Address - Street 1:3223 AVALON DR
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3454
Practice Address - Country:US
Practice Address - Phone:978-884-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered