Provider Demographics
NPI:1417979444
Name:GAUDETTE, LAUREN L (FNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:L
Last Name:GAUDETTE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 COUNTY ROAD 5025
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-8727
Mailing Address - Country:US
Mailing Address - Phone:936-462-3847
Mailing Address - Fax:
Practice Address - Street 1:912 W 12TH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-6005
Practice Address - Country:US
Practice Address - Phone:214-946-6400
Practice Address - Fax:214-946-6402
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP083N6712Medicaid
TX83N671Medicare ID - Type Unspecified
TXP083N6712Medicaid