Provider Demographics
NPI:1558646984
Name:VYVIAL, LAUREN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:VYVIAL
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 1:510 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5033
Mailing Address - Country:US
Mailing Address - Phone:318-281-8109
Mailing Address - Fax:318-281-8099
Practice Address - Street 1:510 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5033
Practice Address - Country:US
Practice Address - Phone:318-281-8109
Practice Address - Fax:318-281-8099
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2193422Medicaid
LA278874YQZTMedicare UPIN