Healthcare Provider Details

I. General information

NPI: 1003309394
Provider Name (Legal Business Name): LATOYA LAWRENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 WISE RD
CONWAY SC
29526-5521
US

IV. Provider business mailing address

2404 WISE RD
CONWAY SC
29526-5521
US

V. Phone/Fax

Practice location:
  • Phone: 843-365-8884
  • Fax:
Mailing address:
  • Phone: 843-365-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: