Healthcare Provider Details

I. General information

NPI: 1770061863
Provider Name (Legal Business Name): LAUREN K EADLINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3229 E GENESEE ST
SYRACUSE NY
13214-2016
US

IV. Provider business mailing address

7517 RIVER RD
BALDWINSVILLE NY
13027-9430
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5726
  • Fax:
Mailing address:
  • Phone: 315-527-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343425
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: