1568972180 NPI number — LAUREN WOMACK

Table of content: LAUREN WOMACK (NPI 1568972180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568972180 NPI number — LAUREN WOMACK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOMACK
Provider First Name:
LAUREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568972180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15260 NW 147TH DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALACHUA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32615-5339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-518-0102
Provider Business Mailing Address Fax Number:
386-518-0116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15260 NW 147TH DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALACHUA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32615-5339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-518-0102
Provider Business Practice Location Address Fax Number:
386-518-0116
Provider Enumeration Date:
10/10/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  ARNP9361727 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ARNP9361727 . This is a "NURSE PRACTITIONER LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 022575100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".