Healthcare Provider Details

I. General information

NPI: 1871435602
Provider Name (Legal Business Name): LAUREN REBECCA PRUDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 ELLIS OAK DR
CHARLESTON SC
29412-3089
US

IV. Provider business mailing address

1674 FOLLY RD APT 526
CHARLESTON SC
29412-8715
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3451
  • Fax:
Mailing address:
  • Phone: 570-394-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL97288
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: