Provider Demographics
NPI:1811542046
Name:HOLDER, LAUREN MONTEON (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MONTEON
Last Name:HOLDER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 AMERBROOK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017
Mailing Address - Country:US
Mailing Address - Phone:770-853-0034
Mailing Address - Fax:
Practice Address - Street 1:3815 HARRISON RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2462
Practice Address - Country:US
Practice Address - Phone:770-466-6112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005328133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty