Provider Demographics
NPI:1659025666
Name:MOCCALDI, LAUREN GRACE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:GRACE
Last Name:MOCCALDI
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 1:2 CRICK HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3813
Mailing Address - Country:US
Mailing Address - Phone:631-316-2562
Mailing Address - Fax:
Practice Address - Street 1:2 CRICK HOLLY LN
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-3813
Practice Address - Country:US
Practice Address - Phone:631-316-2562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant