Provider Demographics
NPI:1740219138
Name:MICKEY, LAUREN JANE (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:JANE
Last Name:MICKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 THOMAS RD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7366
Mailing Address - Country:US
Mailing Address - Phone:318-322-9882
Mailing Address - Fax:318-322-2006
Practice Address - Street 1:102 THOMAS RD
Practice Address - Street 2:SUITE 117
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7366
Practice Address - Country:US
Practice Address - Phone:318-322-9882
Practice Address - Fax:318-322-2006
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.016358174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1441546Medicaid
LA1441546Medicaid
LAB89408Medicare UPIN