Provider Demographics
NPI:1720334212
Name:PROFETA, LAUREN ELIZABETH (LAUREN PROFETA)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:PROFETA
Suffix:
Gender:F
Credentials:LAUREN PROFETA
Other - Prefix:MRS
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:HONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 STEPHEN RD
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1230
Mailing Address - Country:US
Mailing Address - Phone:631-267-5458
Mailing Address - Fax:
Practice Address - Street 1:1363 VETERANS HWY STE 8
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3046
Practice Address - Country:US
Practice Address - Phone:631-366-3876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY622033001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist