Healthcare Provider Details

I. General information

NPI: 1124914940
Provider Name (Legal Business Name): LAURYN RIVERS WELLNESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 PLAZA AMERICA DR STE 2000
RESTON VA
20190-4743
US

IV. Provider business mailing address

11710 PLAZA AMERICA DR STE 2000 PMB 217
RESTON VA
20190
US

V. Phone/Fax

Practice location:
  • Phone: 888-720-7567
  • Fax:
Mailing address:
  • Phone: 888-720-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: