Provider Demographics
NPI:1497536692
Name:BLOXSOME, LAUREN FAITH (RD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:FAITH
Last Name:BLOXSOME
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:
Other - Last Name:SOSA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:3014 VUE AVE UNIT 113
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 W MAIN ST FL 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2824
Practice Address - Country:US
Practice Address - Phone:434-924-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86265415133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered