Provider Demographics
NPI:1295211548
Name:HARGRAVE, LAUREN JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:JOY
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5077
Mailing Address - Country:US
Mailing Address - Phone:815-397-3350
Mailing Address - Fax:
Practice Address - Street 1:621 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5077
Practice Address - Country:US
Practice Address - Phone:815-397-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant