Basic Information
| Provider Information | |||||||||
| NPI: | 1285271411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADDISON | ||||||||
| FirstName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11244 TALAMORE BLVD | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727129033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796856591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1202 SE 30TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792733430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 10/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.