Provider Demographics
NPI:1568938769
Name:PREWITT, LAUREN ASHLEY
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:PREWITT
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:PO BOX 26461
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-6461
Mailing Address - Country:US
Mailing Address - Phone:215-991-9911
Mailing Address - Fax:215-991-9913
Practice Address - Street 1:4943 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-5962
Practice Address - Country:US
Practice Address - Phone:215-991-9911
Practice Address - Fax:215-991-9913
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002719E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024234010001Medicaid