Healthcare Provider Details

I. General information

NPI: 1245327303
Provider Name (Legal Business Name): MARY ELLEN LAWRENCE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1482 S SAINT FRANCIS DR STE C
SANTA FE NM
87505-4098
US

IV. Provider business mailing address

PO BOX 6970
MESA AZ
85216-6970
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-1093
  • Fax:
Mailing address:
  • Phone: 480-985-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY ELLEN LAWRENCE
Title or Position: OWNER
Credential: MD
Phone: 480-985-1093