Provider Demographics
NPI:1932585213
Name:WITHERS, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WITHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HALCYON DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-5332
Mailing Address - Country:US
Mailing Address - Phone:207-317-6466
Mailing Address - Fax:
Practice Address - Street 1:40 FOREST FALLS DR STE 305
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-7010
Practice Address - Country:US
Practice Address - Phone:207-977-4700
Practice Address - Fax:207-977-4900
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1267133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered