Provider Demographics
NPI:1285271411
Name:ADDISON, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ADDISON
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 1:11244 TALAMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9033
Mailing Address - Country:US
Mailing Address - Phone:479-685-6591
Mailing Address - Fax:
Practice Address - Street 1:1202 SE 30TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3779
Practice Address - Country:US
Practice Address - Phone:479-273-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant