Provider Demographics
NPI:1578913596
Name:WILLIS, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WILLIS
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 1:9798 S HIGHWAY 259
Mailing Address - Street 2:
Mailing Address - City:MC DANIELS
Mailing Address - State:KY
Mailing Address - Zip Code:40152-7227
Mailing Address - Country:US
Mailing Address - Phone:270-902-4411
Mailing Address - Fax:
Practice Address - Street 1:9798 S HIGHWAY 259
Practice Address - Street 2:
Practice Address - City:MC DANIELS
Practice Address - State:KY
Practice Address - Zip Code:40152-7227
Practice Address - Country:US
Practice Address - Phone:270-902-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010354363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily