Healthcare Provider Details

I. General information

NPI: 1306922562
Provider Name (Legal Business Name): CLARISSA G LAWRENCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEESA M LAWRENCE MD

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 MEDICAL PARK DR W
WILSON NC
27893-2705
US

IV. Provider business mailing address

1020 TERRACE DR SUITE 101
MARION VA
24354-4392
US

V. Phone/Fax

Practice location:
  • Phone: 252-243-7944
  • Fax: 252-243-6097
Mailing address:
  • Phone: 276-783-8183
  • Fax: 276-782-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101262369
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1306922562
Identifier TypeMEDICAID
Identifier StateVA
Identifier Issuer
# 2
Identifier8951212
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: