=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689922056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN BROOKE ANDERSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2012
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 POWELL VALLEY SCHOOL LN
-----------------------------------------------------
City | SPEEDWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37870-7431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-419-5070
-----------------------------------------------------
Fax | 423-869-0081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 POWELL VALLEY SCHOOL LN
-----------------------------------------------------
City | SPEEDWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37870-7431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-419-5070
-----------------------------------------------------
Fax | 423-869-0081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 99056427A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10001514A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2028
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------