Healthcare Provider Details

I. General information

NPI: 1487201059
Provider Name (Legal Business Name): LAUREN STANDRIDGE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 07/12/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 N OCEAN AVE STE A
MEDFORD NY
11763-2687
US

IV. Provider business mailing address

28 ORCHARD DR
FORT SALONGA NY
11768-2634
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-5858
  • Fax: 631-447-6372
Mailing address:
  • Phone: 631-875-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF344520-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: