Provider Demographics
NPI:1265190276
Name:JOHN, LAUREN NICOLE (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:JOHN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1072 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:12611 N COMMUNITY HOUSE RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3817
Practice Address - Country:US
Practice Address - Phone:704-544-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant