Provider Demographics
NPI:1265102990
Name:SMITH, LAUREN VIRGINIA (PNP)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:VIRGINIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1239
Mailing Address - Country:US
Mailing Address - Phone:618-654-4449
Mailing Address - Fax:618-654-3974
Practice Address - Street 1:1250 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1239
Practice Address - Country:US
Practice Address - Phone:618-654-4449
Practice Address - Fax:618-654-3974
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021994363LP0200X
MO2020042564363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420102808Medicaid