Provider Demographics
NPI:1376353532
Name:NEELY, LAUREN KATE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:KATE
Last Name:NEELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-3506
Mailing Address - Country:US
Mailing Address - Phone:580-747-4707
Mailing Address - Fax:
Practice Address - Street 1:2401 W WRANGLER BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1917
Practice Address - Country:US
Practice Address - Phone:405-382-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5446363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical