Provider Demographics
NPI:1346908019
Name:FENNER, LAUREN M (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:FENNER
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 1:6000 HILLANDALE DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4858
Mailing Address - Country:US
Mailing Address - Phone:470-268-2875
Mailing Address - Fax:
Practice Address - Street 1:795 POPLAR RD STE 400
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2590
Practice Address - Country:US
Practice Address - Phone:770-400-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant