Healthcare Provider Details

I. General information

NPI: 1811542269
Provider Name (Legal Business Name): LAWRENCE LELAND LAKE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PRINCETON AVE SW
BIRMINGHAM AL
35211-1303
US

IV. Provider business mailing address

830 MOONLITE DR
ODENVILLE AL
35120-5463
US

V. Phone/Fax

Practice location:
  • Phone: 205-783-3500
  • Fax:
Mailing address:
  • Phone: 205-441-1483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1-127139
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-127139
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: