Provider Demographics
NPI:1689631590
Name:PHOENIX, LAUREN MARIE (CRNA)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MARIE
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:MARIE
Other - Last Name:MALONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19037 B DRIVE N
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068
Mailing Address - Country:US
Mailing Address - Phone:517-240-9748
Mailing Address - Fax:
Practice Address - Street 1:150 N EAGLE CREEK ST. JOES EAST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-967-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704164418367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104397649Medicaid
MAN47230013Medicare ID - Type UnspecifiedLOC 99