Healthcare Provider Details

I. General information

NPI: 1831853969
Provider Name (Legal Business Name): JAVELIN MONIQUE LAWRENCE CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 MORRISSEY DR STE B
BLOOMINGTON IL
61701-7510
US

IV. Provider business mailing address

1203 MORRISSEY DR STE B
BLOOMINGTON IL
61701-7510
US

V. Phone/Fax

Practice location:
  • Phone: 309-590-6791
  • Fax:
Mailing address:
  • Phone: 309-590-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: