Healthcare Provider Details

I. General information

NPI: 1588160964
Provider Name (Legal Business Name): LAUREN RIDENOUR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 E BANNER GATEWAY DR
GILBERT AZ
85234-2165
US

IV. Provider business mailing address

2946 E BANNER GATEWAY DR
GILBERT AZ
85234-2165
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-6444
  • Fax: 480-256-3682
Mailing address:
  • Phone: 480-256-6444
  • Fax: 480-256-3682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number011029
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number011029
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: