Basic Information
| Provider Information | |||||||||
| NPI: | 1821362385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYCOCK | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMS | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394410247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014257550 | ||||||||
| FaxNumber: | 6013996281 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014257522 | ||||||||
| FaxNumber: | 6014257524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2012 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R881219 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | R881219 | MS | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 03101303 | 05 | MS | MEDICAID |