Basic Information
Provider Information | |||||||||
NPI: | 1124310149 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICKOFF | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KENT | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 531 ROSELANE ST NW STE 710 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300606975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783313297 | ||||||||
FaxNumber: | 6785817187 | ||||||||
Practice Location | |||||||||
Address1: | 340 KENNESTONE HOSPITAL BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702815100 | ||||||||
FaxNumber: | 6785817100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2011 | ||||||||
LastUpdateDate: | 06/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 006092 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1124310149 | 01 | GA | NPI NUMBER | OTHER |