Provider Demographics
NPI:1821362385
Name:AYCOCK, LAUREN S (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:S
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:RENEE
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-425-7550
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:1410 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4243
Practice Address - Country:US
Practice Address - Phone:601-425-7522
Practice Address - Fax:601-425-7524
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881219363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03101303Medicaid
MS03101303Medicaid