Provider Demographics
NPI:1639942279
Name:WILLIE, LAUREN REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:REBECCA
Last Name:WILLIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 OLD BERWICK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-3223
Mailing Address - Country:US
Mailing Address - Phone:570-394-2506
Mailing Address - Fax:
Practice Address - Street 1:125 SMITHFIELD LN
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8715
Practice Address - Country:US
Practice Address - Phone:272-212-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006722363A00000X
PAMA065189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant