Healthcare Provider Details

I. General information

NPI: 1609699339
Provider Name (Legal Business Name): LAWRENCIA I ENYIOHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MADISON ST
SYRACUSE NY
13210-2319
US

IV. Provider business mailing address

6886 HEARTHSTONE LN
LIVERPOOL NY
13088-5904
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-3600
  • Fax:
Mailing address:
  • Phone: 609-433-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number650856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: