Provider Demographics
NPI:1558373340
Name:PROCTOR, J'LAINE (FNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:J'LAINE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:JALAINE
Other - Last Name:LLOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1465 N 4TH ST
Mailing Address - Street 2:SUITE 119
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2066
Mailing Address - Country:US
Mailing Address - Phone:307-721-0700
Mailing Address - Fax:307-721-1039
Practice Address - Street 1:1465 N 4TH ST
Practice Address - Street 2:SUITE #119
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2066
Practice Address - Country:US
Practice Address - Phone:307-721-0700
Practice Address - Fax:307-721-1039
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY199070282363LA2200X
WY19907.0282363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120576500Medicaid
WY120576500Medicaid
Q36988Medicare UPIN