Provider Demographics
NPI:1043658032
Name:PETERSON, LAUREN BROOKE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:BROOKE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4812 DEER CREEK PL
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40068-7899
Mailing Address - Country:US
Mailing Address - Phone:502-836-8291
Mailing Address - Fax:
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program