Healthcare Provider Details

I. General information

NPI: 1336605179
Provider Name (Legal Business Name): MRS. LAUREN POLLARD WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SPRING HILL AVE
MOBILE AL
36604-1407
US

IV. Provider business mailing address

320 DALEWOOD DR
MOBILE AL
36608-1507
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-143583
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-143583
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: