Provider Demographics
NPI:1073264610
Name:MARANDINO, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MARANDINO
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 1:115 S 2ND ST # 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-5206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 S 2ND ST APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-5241
Practice Address - Country:US
Practice Address - Phone:860-573-7432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2023-03-15
Deactivation Date:2022-11-09
Deactivation Code:
Reactivation Date:2022-11-21
Provider Licenses
StateLicense IDTaxonomies
NYF404586-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty