Provider Demographics
NPI:1629749544
Name:LIFESTYLE NUTRITION AND WELLNESS, LLC
Entity Type:Organization
Organization Name:LIFESTYLE NUTRITION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURBONNAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, RD, LDN
Authorized Official - Phone:248-909-8555
Mailing Address - Street 1:9800 MOODY CT
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-6643
Mailing Address - Country:US
Mailing Address - Phone:248-909-8555
Mailing Address - Fax:
Practice Address - Street 1:9800 MOODY CT
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-6643
Practice Address - Country:US
Practice Address - Phone:248-909-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty