Basic Information
| Provider Information | |||||||||
| NPI: | 1710127261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DARK | ||||||||
| FirstName: | LELA | ||||||||
| MiddleName: | KRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1051 TALBOTTON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319048745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063222511 | ||||||||
| FaxNumber: | 7063220913 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 TALBOTTON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319048745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063222511 | ||||||||
| FaxNumber: | 7063220913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2009 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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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 | 1-077179 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RN222649 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 510-70395 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |