Provider Demographics
NPI:1679112858
Name:BAXTER, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 DEVONSHIRE CT APT 3
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-4186
Mailing Address - Country:US
Mailing Address - Phone:608-963-8083
Mailing Address - Fax:
Practice Address - Street 1:2558 POST RD
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-3331
Practice Address - Country:US
Practice Address - Phone:715-600-2798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3458-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered