Healthcare Provider Details

I. General information

NPI: 1326203589
Provider Name (Legal Business Name): NICOLE TERESA LAWRENCE M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MACK BAYOU LOOP STE 100
SANTA ROSA BEACH FL
32459-2606
US

IV. Provider business mailing address

PO BOX 2699
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-1575
  • Fax:
Mailing address:
  • Phone: 850-475-4686
  • Fax: 850-475-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberME111073
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: