Provider Demographics
NPI:1285126565
Name:RILEY, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 STONE LN APT 5207
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-1574
Mailing Address - Country:US
Mailing Address - Phone:949-230-9051
Mailing Address - Fax:
Practice Address - Street 1:55 BEARSE AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5823
Practice Address - Country:US
Practice Address - Phone:949-230-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2297684163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse