Basic Information
| Provider Information | |||||||||
| NPI: | 1336554369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLMGREN | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707828700 | ||||||||
| FaxNumber: | 2707828704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 ASHLEY CIR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707828700 | ||||||||
| FaxNumber: | 2707828704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125.065068 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 50108 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100452090 | 05 | KY | MEDICAID |