Healthcare Provider Details

I. General information

NPI: 1265763668
Provider Name (Legal Business Name): LAUREN AMBROSIA DALEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PAVILION DR SUITE 108
KINGSPORT TN
37660-4657
US

IV. Provider business mailing address

2204 PAVILION DR SUITE 108
KINGSPORT TN
37660-4657
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6100
  • Fax: 423-392-6159
Mailing address:
  • Phone: 423-392-6100
  • Fax: 423-392-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000014653
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: