1386897981 NPI number — MRS. LAUREN ANNE CLONAN

Table of content: MRS. LAUREN ANNE CLONAN (NPI 1386897981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386897981 NPI number — MRS. LAUREN ANNE CLONAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLONAN
Provider First Name:
LAUREN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386897981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7367 COFFEEMILL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVERPOOL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13088-4709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-451-1925
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
299 DONLIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVERPOOL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-453-0249
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  014150-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: 014150 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 014150 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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