Healthcare Provider Details

I. General information

NPI: 1194732818
Provider Name (Legal Business Name): LAUREN HARRALL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN GOLEY ATC

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 KEANEY ROAD SUITE ONE
KINGSTON RI
02881
US

IV. Provider business mailing address

3 KEANEY ROAD SUITE ONE
KINGSTON RI
02881
US

V. Phone/Fax

Practice location:
  • Phone: 401-874-2051
  • Fax: 401-874-4804
Mailing address:
  • Phone: 401-874-2051
  • Fax: 401-874-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT00232
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: