Healthcare Provider Details

I. General information

NPI: 1730699091
Provider Name (Legal Business Name): LAUREN GIBBONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2017
Last Update Date: 10/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR STE LL108
PLAINVIEW NY
11803-1707
US

IV. Provider business mailing address

2177 SANDERS PL
NORTH BELLMORE NY
11710-1551
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-2040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: