Healthcare Provider Details

I. General information

NPI: 1124724661
Provider Name (Legal Business Name): LAUREN RAE FOLLIS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY ST
NORMAL IL
61761-4402
US

IV. Provider business mailing address

107 N ORR DR APT E
NORMAL IL
61761-1975
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-8661
  • Fax:
Mailing address:
  • Phone: 309-231-3765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.005344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: