Healthcare Provider Details

I. General information

NPI: 1164017695
Provider Name (Legal Business Name): MARY JO LAWRENCE CNMT, RT, RS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 DIPLOMAT PKWY E
CAPE CORAL FL
33909-5422
US

IV. Provider business mailing address

2489 DIPLOMAT PKWY E
CAPE CORAL FL
33909-5422
US

V. Phone/Fax

Practice location:
  • Phone: 239-652-1800
  • Fax:
Mailing address:
  • Phone: 239-652-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number14605
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License NumberCRT51441
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: