Healthcare Provider Details

I. General information

NPI: 1154412401
Provider Name (Legal Business Name): MARISA LAWRENCE MD PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FY RD NE STE 110
ATLANTA GA
30342-1607
US

IV. Provider business mailing address

980 JOHNSON FY RD NE STE 110
ATLANTA GA
30342-1607
US

V. Phone/Fax

Practice location:
  • Phone: 404-303-7004
  • Fax: 404-303-7020
Mailing address:
  • Phone: 404-303-7004
  • Fax: 404-303-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number582261832
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number38839
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: