Provider Demographics
NPI:1073929386
Name:CLARKSBURG PEDIATRICS LLC
Entity Type:Organization
Organization Name:CLARKSBURG PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PRIMARY CARE NP
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP-PC, IBCLC
Authorized Official - Phone:301-412-7278
Mailing Address - Street 1:23218 BREWERS TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4391
Mailing Address - Country:US
Mailing Address - Phone:301-528-8181
Mailing Address - Fax:
Practice Address - Street 1:23218 BREWERS TAVERN WAY
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4391
Practice Address - Country:US
Practice Address - Phone:301-528-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR186838363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty