Provider Demographics
NPI:1699502138
Name:SMITH, LAUREN KATHLEEN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:KATHLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:KATHLEEN
Other - Last Name:BRUNNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9039 W BROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5842
Mailing Address - Country:US
Mailing Address - Phone:804-562-0814
Mailing Address - Fax:
Practice Address - Street 1:9039 W BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-5842
Practice Address - Country:US
Practice Address - Phone:804-562-0814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA158210966793175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist