Provider Demographics
NPI:1265763668
Name:DALEY, LAUREN AMBROSIA (NP)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:AMBROSIA
Last Name:DALEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 PAVILION DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4657
Mailing Address - Country:US
Mailing Address - Phone:423-392-6100
Mailing Address - Fax:423-392-6159
Practice Address - Street 1:2204 PAVILION DR
Practice Address - Street 2:SUITE 108
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4657
Practice Address - Country:US
Practice Address - Phone:423-392-6100
Practice Address - Fax:423-392-6159
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000014653363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1265763668Medicaid
TN1519308Medicaid
TN4299418OtherBCBS TENNESSEE
TN4299418OtherBCBS TENNESSEE