Provider Demographics
NPI:1083915300
Name:LAWRENCE, NICOLE SAMANTHA (DBH, MPH, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SAMANTHA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:DBH, MPH, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 KALEY WALK NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2685
Mailing Address - Country:US
Mailing Address - Phone:770-417-0512
Mailing Address - Fax:
Practice Address - Street 1:2483 KALEY WALK NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-2685
Practice Address - Country:US
Practice Address - Phone:770-417-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004834133V00000X
MDDX3096133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered