Provider Demographics
NPI:1891253514
Name:BOETTCHER, LAUREN M
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:BOETTCHER
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 1:38 STRATTON LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3222
Mailing Address - Country:US
Mailing Address - Phone:631-905-6843
Mailing Address - Fax:
Practice Address - Street 1:38 STRATTON LN
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3222
Practice Address - Country:US
Practice Address - Phone:631-905-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty