Healthcare Provider Details

I. General information

NPI: 1760377634
Provider Name (Legal Business Name): DEREK NEIL LAWRENCE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LAKEMONT AVE FL 32792
WINTER PARK FL
32792-3273
US

IV. Provider business mailing address

200 N LAKEMONT AVE FL 32792
WINTER PARK FL
32792-3273
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number10677
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: