Provider Demographics
NPI:1114512050
Name:CASTILLO, LAUREN MELISSA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MELISSA
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 CONINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-5403
Mailing Address - Country:US
Mailing Address - Phone:229-269-7487
Mailing Address - Fax:
Practice Address - Street 1:2409 N PATTERSON ST STE 200
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2512
Practice Address - Country:US
Practice Address - Phone:229-333-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN251943363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2019049126OtherANCC CERTIFICATION
GARN251943OtherAPRN LICENSURE