Healthcare Provider Details

I. General information

NPI: 1497456321
Provider Name (Legal Business Name): LAUREN ELIZABETH STATON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 S LABURNUM AVE
RICHMOND VA
23231-2712
US

IV. Provider business mailing address

7310 LAKESHORE DR
QUINTON VA
23141-1155
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-1000
  • Fax:
Mailing address:
  • Phone: 804-614-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605809
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: