Provider Demographics
NPI:1730428129
Name:DOUGLASS, LAUREN ELIZABETH (CRNA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:DEMARCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 GOOD SAMARITAN WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2402
Mailing Address - Country:US
Mailing Address - Phone:618-241-1108
Mailing Address - Fax:
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-241-1108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010201367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered