Healthcare Provider Details

I. General information

NPI: 1306498548
Provider Name (Legal Business Name): LAUREN THORNTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E CARTER AVE
BLACKSHEAR GA
31516-1561
US

IV. Provider business mailing address

4362 MEADOW WOOD RD
BLACKSHEAR GA
31516-4519
US

V. Phone/Fax

Practice location:
  • Phone: 912-449-4426
  • Fax: 912-449-1059
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN170290
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: