Provider Demographics
NPI:1710127261
Name:DARK, LELA KRISTINE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LELA
Middle Name:KRISTINE
Last Name:DARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 TALBOTTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8745
Mailing Address - Country:US
Mailing Address - Phone:706-322-2511
Mailing Address - Fax:706-322-0913
Practice Address - Street 1:1051 TALBOTTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8745
Practice Address - Country:US
Practice Address - Phone:706-322-2511
Practice Address - Fax:706-322-0913
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-077179363L00000X
GARN222649363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-70395OtherBLUE CROSS BLUE SHIELD