Provider Demographics
NPI:1639547441
Name:IACOVINO, LAUREN (BSN, MS, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:IACOVINO
Suffix:
Gender:F
Credentials:BSN, MS, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2834
Mailing Address - Country:US
Mailing Address - Phone:617-533-2400
Mailing Address - Fax:
Practice Address - Street 1:398 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3134
Practice Address - Country:US
Practice Address - Phone:617-282-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2299333163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0026023OtherMEDICARE
MA1305395Medicaid