Provider Demographics
NPI:1164101267
Name:PAVLOV, LAUREN RENEE (RD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:RENEE
Last Name:PAVLOV
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:RENEE
Other - Last Name:DYKSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CNSC
Mailing Address - Street 1:4741 DEXTER PINCKNEY RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-8536
Mailing Address - Country:US
Mailing Address - Phone:248-930-4573
Mailing Address - Fax:
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4418
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered