Healthcare Provider Details

I. General information

NPI: 1225220411
Provider Name (Legal Business Name): MARY JO LAWRENCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10696 CRESTWOOD DR STE B
MANASSAS VA
20109-4411
US

IV. Provider business mailing address

4601 WESTON ROAD RTE 747
CASANOVA VA
20139
US

V. Phone/Fax

Practice location:
  • Phone: 703-368-7110
  • Fax:
Mailing address:
  • Phone: 540-788-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number0024134318
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: