Provider Demographics
NPI:1497333108
Name:BONGIORNO, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BONGIORNO
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 1:156 LANDING MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1100
Mailing Address - Country:US
Mailing Address - Phone:631-626-6377
Mailing Address - Fax:
Practice Address - Street 1:156 LANDING MEADOW RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1100
Practice Address - Country:US
Practice Address - Phone:631-626-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Identifiers
StateIdentifier IDID TypeIssuer
0708OtherDONT HAVE