Provider Demographics
NPI:1578187928
Name:DOUGLAS, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:DOUGLAS
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 1:1030 REED AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-2039
Mailing Address - Country:US
Mailing Address - Phone:610-816-5848
Mailing Address - Fax:610-376-1320
Practice Address - Street 1:1030 REED AVE STE 114
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-2039
Practice Address - Country:US
Practice Address - Phone:610-816-5848
Practice Address - Fax:610-376-1320
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022036363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner