Provider Demographics
NPI:1649514597
Name:ROUGHTON, LORI L (NP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:ROUGHTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MONTAUK HWY
Mailing Address - Street 2:BOX 1555
Mailing Address - City:QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11959-4000
Mailing Address - Country:US
Mailing Address - Phone:631-653-6000
Mailing Address - Fax:631-653-8310
Practice Address - Street 1:33 MONTAUK HWY
Practice Address - Street 2:BOX 1555
Practice Address - City:QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11959-4000
Practice Address - Country:US
Practice Address - Phone:631-653-6000
Practice Address - Fax:631-653-8310
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30306135363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health