Healthcare Provider Details

I. General information

NPI: 1396143624
Provider Name (Legal Business Name): LAURIE YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GOVERNORS AVE
MEDFORD MA
02155-1643
US

IV. Provider business mailing address

170 GOVERNORS AVE
MEDFORD MA
02155-1643
US

V. Phone/Fax

Practice location:
  • Phone: 781-979-2424
  • Fax: 781-338-7557
Mailing address:
  • Phone: 781-979-2424
  • Fax: 781-338-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN228119
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: