Healthcare Provider Details

I. General information

NPI: 1881556652
Provider Name (Legal Business Name): BRANDON LAWRENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3789 WOOD CIR
COCOA FL
32926-4828
US

IV. Provider business mailing address

3789 WOOD CIR
COCOA FL
32926-4828
US

V. Phone/Fax

Practice location:
  • Phone: 321-506-7362
  • Fax:
Mailing address:
  • Phone: 321-506-7362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number960951
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: