Provider Demographics
NPI:1790244259
Name:LAWRENCE, NICOLE BENNETT (RD, LDN, MSCN)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BENNETT
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:RD, LDN, MSCN
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ALEXIS
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 ORLEANS ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8815
Practice Address - Country:US
Practice Address - Phone:717-843-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDX4631Medicaid