Healthcare Provider Details

I. General information

NPI: 1588924039
Provider Name (Legal Business Name): LAUREN MANSOUR CNA, CHHA, LTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN DOTY

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3517 E GILLETTE ST
BROKEN ARROW OK
74014-8867
US

IV. Provider business mailing address

3517 E GILLETTE ST
BROKEN ARROW OK
74014-8867
US

V. Phone/Fax

Practice location:
  • Phone: 191-860-6988
  • Fax:
Mailing address:
  • Phone: 191-860-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number37V243121202
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number37V243111202
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: