Provider Demographics
NPI:1619546454
Name:PROSTROLLO, LAUREN RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:RUSSELL
Last Name:PROSTROLLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4717
Mailing Address - Country:US
Mailing Address - Phone:904-308-7372
Mailing Address - Fax:
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4717
Practice Address - Country:US
Practice Address - Phone:904-308-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO7731390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program