Provider Demographics
NPI:1235538091
Name:ANTONISON, LAUREN (FNP-BC)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ANTONISON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MANTUA PIKE STE 720-208
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1606
Mailing Address - Country:US
Mailing Address - Phone:856-684-0326
Mailing Address - Fax:
Practice Address - Street 1:213 WESTWOOD CT
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3134
Practice Address - Country:US
Practice Address - Phone:856-684-0326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00515000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily