Provider Demographics
NPI:1164071700
Name:WELTON, LAUREN E
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:E
Last Name:WELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-3302
Mailing Address - Fax:918-943-7589
Practice Address - Street 1:11362 COUNTRY CLUB ROAD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439
Practice Address - Country:US
Practice Address - Phone:618-943-3302
Practice Address - Fax:618-943-7589
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376006178Medicaid