Provider Demographics
NPI:1558775411
Name:LEY, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:LEY
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 603
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-0603
Mailing Address - Country:US
Mailing Address - Phone:229-232-8052
Mailing Address - Fax:
Practice Address - Street 1:106 W THIGPEN AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-1011
Practice Address - Country:US
Practice Address - Phone:229-232-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162601363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health