Provider Demographics
NPI:1831394782
Name:LAMPLEY-DOUGLASS, JULIE A (PA-C)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:LAMPLEY-DOUGLASS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:LAMPLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4105 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6296
Mailing Address - Country:US
Mailing Address - Phone:618-246-2910
Mailing Address - Fax:618-246-2912
Practice Address - Street 1:4105 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-246-2910
Practice Address - Fax:618-246-2912
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002864363AS0400X
IL085-002864363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7210895OtherAETNA GROUP NUMBER
IL3932056OtherBCBS GROUP NUMBER
IL7210895OtherAETNA GROUP NUMBER