Provider Demographics
NPI:1134757438
Name:FICKETT, LAUREN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:FICKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 SPRING LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-4914
Mailing Address - Country:US
Mailing Address - Phone:716-982-6910
Mailing Address - Fax:
Practice Address - Street 1:726 EXCHANGE ST STE 710
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1464
Practice Address - Country:US
Practice Address - Phone:716-852-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant