Provider Demographics
NPI:1578106753
Name:RICOSSA, LAUREN GAYLE (FNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:GAYLE
Last Name:RICOSSA
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:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:GEORGE WEST
Mailing Address - State:TX
Mailing Address - Zip Code:78022-1139
Mailing Address - Country:US
Mailing Address - Phone:409-679-3091
Mailing Address - Fax:
Practice Address - Street 1:2908 FERN LAKE CUTOFF
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-1593
Practice Address - Country:US
Practice Address - Phone:409-679-3091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142292363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner