Provider Demographics
NPI:1790219020
Name:KELLY, LAUREN SMITH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:SMITH
Last Name:KELLY
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 1:495 S COOKS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2968
Mailing Address - Country:US
Mailing Address - Phone:732-616-0398
Mailing Address - Fax:
Practice Address - Street 1:185 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2757
Practice Address - Country:US
Practice Address - Phone:973-972-4417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program