=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447686829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN WILDER REACH APRN, CPNP-AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2013
-----------------------------------------------------
Last Update Date | 11/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 BARBARA JORDAN BLVD
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-628-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12413 CARDINAL FLOWER DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78739-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-897-8101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 717326
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------