Provider Demographics
NPI:1790093011
Name:SMITH, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SMITH
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 1:2435 W BELVEDERE AVE
Mailing Address - Street 2:SUITE 42
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5224
Mailing Address - Country:US
Mailing Address - Phone:410-601-5547
Mailing Address - Fax:
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 42
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR148992363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS644Medicare PIN
MD187369ZA97Medicare PIN