Healthcare Provider Details

I. General information

NPI: 1477210581
Provider Name (Legal Business Name): LAUREN AULTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S 19TH AVE
HATTIESBURG MS
39401-6171
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-4601
  • Fax: 601-582-1607
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number330477
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: