=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497456321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ELIZABETH STATON PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4730 S LABURNUM AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23231-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-764-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7310 LAKESHORE DR
-----------------------------------------------------
City | QUINTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23141-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-614-1840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306605809
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------