Provider Demographics
NPI:1124173885
Name:DIMITROV, LAUREN TINA (RD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:TINA
Last Name:DIMITROV
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-493-3333
Mailing Address - Fax:904-493-2222
Practice Address - Street 1:7011 A C SKINNER PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6954
Practice Address - Country:US
Practice Address - Phone:904-493-3333
Practice Address - Fax:904-493-2222
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5498133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered