Provider Demographics
NPI:1114223104
Name:BAUMGARDNER, LORI WATSON (RD)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:WATSON
Last Name:BAUMGARDNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:ELAINE
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:165 PEPPERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2070
Mailing Address - Country:US
Mailing Address - Phone:276-223-5400
Mailing Address - Fax:276-223-5454
Practice Address - Street 1:165 PEPPERS FERRY RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2070
Practice Address - Country:US
Practice Address - Phone:276-223-5400
Practice Address - Fax:276-223-5454
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003718133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2995088OtherMEDICARE PTAN