Provider Demographics
NPI:1063176972
Name:MICALIZIO, LAUREN (FNP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MICALIZIO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 WELLINGTON TER
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3451
Mailing Address - Country:US
Mailing Address - Phone:407-808-2292
Mailing Address - Fax:
Practice Address - Street 1:1801 PEACHREE ST.
Practice Address - Street 2:SUITE 145
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:770-800-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45058207RR0500X
GAF10210959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty