Provider Demographics
NPI:1609201565
Name:ANTONELLI, LAUREN MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4079
Mailing Address - Country:US
Mailing Address - Phone:631-689-6698
Mailing Address - Fax:631-751-5548
Practice Address - Street 1:6 TECHNOLOGY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4079
Practice Address - Country:US
Practice Address - Phone:631-689-6698
Practice Address - Fax:631-751-5548
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant