Provider Demographics
NPI:1831962406
Name:CISLO, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:CISLO
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 1:2153 LAKEVIEW DR APT 38
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-6708
Mailing Address - Country:US
Mailing Address - Phone:734-558-2066
Mailing Address - Fax:
Practice Address - Street 1:37000 GRAND RIVER AVE STE 310
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2868
Practice Address - Country:US
Practice Address - Phone:248-536-2127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant