Provider Demographics
NPI:1942834528
Name:RAY-VILLALOBOS, LAUREN ASHLEY
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:RAY-VILLALOBOS
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:
Practice Address - Street 1:86 WREN ST
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-1529
Practice Address - Country:US
Practice Address - Phone:803-259-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24200363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCI939OtherMEDICARE
SC24200OtherMEDICAL LICENSE
SCNP7097Medicaid