Healthcare Provider Details

I. General information

NPI: 1235279407
Provider Name (Legal Business Name): LAUREN JO HAVENS MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 E GENESEE ST
FAYETTEVILLE NY
13066-1536
US

IV. Provider business mailing address

4605 PEWTER LN
MANLIUS NY
13104-9329
US

V. Phone/Fax

Practice location:
  • Phone: 315-968-2733
  • Fax: 315-305-5029
Mailing address:
  • Phone: 315-968-2733
  • Fax: 315-305-5029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number334767
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: