Healthcare Provider Details

I. General information

NPI: 1851829972
Provider Name (Legal Business Name): LAUREN ELAINE PROVINI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WOODLAND RD STE 1
MADISON CT
06443-2380
US

IV. Provider business mailing address

11 WOODLAND RD STE 1
MADISON CT
06443-2380
US

V. Phone/Fax

Practice location:
  • Phone: 203-421-2055
  • Fax: 203-868-0882
Mailing address:
  • Phone: 203-421-2055
  • Fax: 203-868-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number70873
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: