Provider Demographics
NPI:1811948391
Name:LARSEN DWYER, LENORE ELIZABETH (RD LDN)
Entity type:Individual
Prefix:MS
First Name:LENORE
Middle Name:ELIZABETH
Last Name:LARSEN DWYER
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 AUTUMN ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-1301
Mailing Address - Country:US
Mailing Address - Phone:844-328-9473
Mailing Address - Fax:724-375-2435
Practice Address - Street 1:99 AUTUMN ST
Practice Address - Street 2:SUITE N
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1301
Practice Address - Country:US
Practice Address - Phone:844-328-9473
Practice Address - Fax:724-375-2435
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000793133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001525262Medicaid