Healthcare Provider Details

I. General information

NPI: 1992764401
Provider Name (Legal Business Name): LAUREN B CIANCIARUSO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 11/27/2023
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711C E MAIN ST
PURCELLVILLE VA
20132-3178
US

IV. Provider business mailing address

711C E MAIN ST
PURCELLVILLE VA
20132-3178
US

V. Phone/Fax

Practice location:
  • Phone: 540-338-7116
  • Fax: 540-338-6671
Mailing address:
  • Phone: 540-338-7116
  • Fax: 540-338-6671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102201343
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2104
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: