Provider Demographics
NPI:1144465881
Name:OBLAK, LAUREN KIMBERLY
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:KIMBERLY
Last Name:OBLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 MAGNOLIA PKWY
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-3087
Mailing Address - Country:US
Mailing Address - Phone:706-836-8845
Mailing Address - Fax:
Practice Address - Street 1:2922 PROFESSIONAL PKWY STE A
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-6532
Practice Address - Country:US
Practice Address - Phone:706-855-2767
Practice Address - Fax:706-855-7077
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant