Provider Demographics
NPI:1215204375
Name:DUBBERLY, LAUREN M (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:DUBBERLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0138
Mailing Address - Country:US
Mailing Address - Phone:502-663-3326
Mailing Address - Fax:
Practice Address - Street 1:948 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0138
Practice Address - Country:US
Practice Address - Phone:502-663-3326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001333A363A00000X
GA007777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201125230Medicaid
IN201125230Medicaid