Basic Information
| Provider Information | |||||||||
| NPI: | 1265763668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALEY | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | AMBROSIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926100 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926100 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000014653 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1265763668 | 05 | VA | MEDICAID | 1519308 | 05 | TN | MEDICAID | 4299418 | 01 | TN | BCBS TENNESSEE | OTHER |