Provider Demographics
NPI:1669817011
Name:HENDERSON, LAUREN I (MD)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:I
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:HENDERSON
Other - Last Name:LOMAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1550 MULKEY RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1112
Mailing Address - Country:US
Mailing Address - Phone:770-732-1137
Mailing Address - Fax:770-732-2081
Practice Address - Street 1:1550 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1112
Practice Address - Country:US
Practice Address - Phone:707-321-1377
Practice Address - Fax:770-732-2081
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86208207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003244191GMedicaid