Healthcare Provider Details

I. General information

NPI: 1700475233
Provider Name (Legal Business Name): LAWRENCE JOSEPH WURN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4421 NW 39TH AVE STE 2-2
GAINESVILLE FL
32606-7214
US

IV. Provider business mailing address

4421 NW 39TH AVE STE 2-2
GAINESVILLE FL
32606-7214
US

V. Phone/Fax

Practice location:
  • Phone: 352-336-1433
  • Fax: 352-336-9980
Mailing address:
  • Phone: 352-336-1433
  • Fax: 352-336-9980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA11614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: