Provider Demographics
NPI:1669890679
Name:WILSON, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WILSON
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 1:4425 PORTSMOUTH BLVD
Mailing Address - Street 2:SUITE 210E
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2152
Mailing Address - Country:US
Mailing Address - Phone:757-230-0056
Mailing Address - Fax:757-809-5688
Practice Address - Street 1:4425 PORTSMOUTH BLVD
Practice Address - Street 2:SUITE 210E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2152
Practice Address - Country:US
Practice Address - Phone:757-230-0056
Practice Address - Fax:757-809-5688
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAHCO-161137Medicaid