=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417506791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN PATIENCE PURDY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2019
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 45TH ST
-----------------------------------------------------
City | MANGONIA PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33407-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-844-5255
-----------------------------------------------------
Fax | 561-844-5245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MARYLAND FARMS STE 200
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA9112531
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9112531
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------