Healthcare Provider Details

I. General information

NPI: 1205477510
Provider Name (Legal Business Name): LAUREN NICOLE MAIN RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N DICKINSON DR
RUSK TX
75785-1006
US

IV. Provider business mailing address

PO BOX 318
RUSK TX
75785-0318
US

V. Phone/Fax

Practice location:
  • Phone: 903-683-3421
  • Fax: 903-683-7199
Mailing address:
  • Phone: 903-683-3421
  • Fax: 903-683-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP142014
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: