MEDICARE: LAUREN WIDMAN RN, NP-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN711221	OTHER	GA	REGISTERED NURSE

General Provider Information

NPI Number	:	1205778164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN WIDMAN RN, NP-S

Provider Business Mailing Address
First Line	:	11000 WILSHIRE CHASE DR
Second Line	:
City	:	JOHNS CREEK
State	:	GA
Zip	:	30097-1797
Country	:	US
Telephone Number	:	770-286-0997
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 CLIFTON RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-4201
Country	:	US
Telephone Number	:	404-727-7980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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