Provider Demographics
NPI:1679826697
Name:BOVELLE, LAUREN E (RPA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:BOVELLE
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 VAN COTT RD STE 2E
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6519
Mailing Address - Country:US
Mailing Address - Phone:631-274-0777
Mailing Address - Fax:
Practice Address - Street 1:16 VAN COTT RD STE 2E
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-6519
Practice Address - Country:US
Practice Address - Phone:631-274-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP86106363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400091626Medicare PIN