Provider Demographics
NPI:1326283011
Name:WHEATON, LAURIN REVERE (ACNP)
Entity Type:Individual
Prefix:
First Name:LAURIN
Middle Name:REVERE
Last Name:WHEATON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 WINDCROSS CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2678
Mailing Address - Country:US
Mailing Address - Phone:615-946-4519
Mailing Address - Fax:615-658-5142
Practice Address - Street 1:1009 WINDCROSS CT
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2678
Practice Address - Country:US
Practice Address - Phone:615-946-4519
Practice Address - Fax:615-658-5142
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13815363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510016OtherMCC-MEDICAID-TN
TN1510016Medicaid
TN33425131Medicare PIN