Provider Demographics
NPI:1164130506
Name:ZIDEK, LAUREN ASHLEY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:ZIDEK
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:PO BOX 1945
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28402-1945
Mailing Address - Country:US
Mailing Address - Phone:910-341-4556
Mailing Address - Fax:866-363-8330
Practice Address - Street 1:122 OKATIE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909
Practice Address - Country:US
Practice Address - Phone:843-706-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered