Healthcare Provider Details

I. General information

NPI: 1497129134
Provider Name (Legal Business Name): LAUREN BACKY CNM, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SAM PERRY BLVD SUITE 401
FREDERICKSBURG VA
22401-4467
US

IV. Provider business mailing address

18315 CONGRESSIONAL CIR
RUTHER GLEN VA
22546-2957
US

V. Phone/Fax

Practice location:
  • Phone: 540-940-2000
  • Fax:
Mailing address:
  • Phone: 804-405-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0024173062
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024173062
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: