1538753330 NPI number — LAUREN N FATER OT

Table of content: LAUREN N FATER OT (NPI 1538753330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538753330 NPI number — LAUREN N FATER OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FATER
Provider First Name:
LAUREN
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DRISCOLL
Provider Other First Name:
LAUREN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
0T
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538753330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 117345
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-7345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-346-3465
Provider Business Mailing Address Fax Number:
904-858-6489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14534 OLD SAINT AUGUSTINE RD STE 3220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-288-9491
Provider Business Practice Location Address Fax Number:
904-288-9698
Provider Enumeration Date:
02/23/2021

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: 225X00000X , with the licence number:  OT21518 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109827900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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