Healthcare Provider Details

I. General information

NPI: 1669019501
Provider Name (Legal Business Name): LORIE LYNN SIDERS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

IV. Provider business mailing address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-8356
  • Fax:
Mailing address:
  • Phone: 740-395-8356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09000
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: