Basic Information
| Provider Information | |||||||||
| NPI: | 1619200920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | HART | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOWNIE | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | HART | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 FLAT ROCK PL | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | WESTBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064981565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603583640 | ||||||||
| FaxNumber: | 8603588656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2009 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA3863 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 002300 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.