Provider Demographics
NPI:1427660810
Name:COLACICCO, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:COLACICCO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FOREST DR APT A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-4128
Mailing Address - Country:US
Mailing Address - Phone:973-600-8158
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:973-322-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY027304-01363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical