Healthcare Provider Details

I. General information

NPI: 1366352064
Provider Name (Legal Business Name): LAUREN BRACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 WYOMING AVE
SCRANTON PA
18509-3023
US

IV. Provider business mailing address

86 JAMES ST
SHAVERTOWN PA
18708-1518
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-9684
  • Fax:
Mailing address:
  • Phone: 570-394-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSP037079
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: