Provider Demographics
NPI:1235252065
Name:KOHLBERG, LAUREN ILLYA (CPNP)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ILLYA
Last Name:KOHLBERG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 ZEPPI LN
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4130
Mailing Address - Country:US
Mailing Address - Phone:973-736-3690
Mailing Address - Fax:
Practice Address - Street 1:1500 PLEASANT VALLEY WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2956
Practice Address - Country:US
Practice Address - Phone:973-243-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO12100400363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics