Provider Demographics
NPI:1861534364
Name:LAKE NORMAN NUTRITION ASSOCIATES, LLC
Entity type:Organization
Organization Name:LAKE NORMAN NUTRITION ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN,DIABETES EDUCATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIN
Authorized Official - Middle Name:KIMBERLY
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD,LDN,CDE
Authorized Official - Phone:704-576-5001
Mailing Address - Street 1:19809 NORTHCOVE RD # B
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6445
Mailing Address - Country:US
Mailing Address - Phone:704-895-9865
Mailing Address - Fax:704-895-9870
Practice Address - Street 1:16501 NORTHCROSS DR STE D
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5040
Practice Address - Country:US
Practice Address - Phone:704-895-9865
Practice Address - Fax:704-895-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001079133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty