Provider Demographics
NPI:1942793427
Name:WILEY, LAUREN NICOLE (PA)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:NICOLE
Last Name:WILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:NICOLE
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10010 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2106
Mailing Address - Country:US
Mailing Address - Phone:314-525-4137
Mailing Address - Fax:
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008953363A00000X
MO2022039861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant