Healthcare Provider Details

I. General information

NPI: 1124667266
Provider Name (Legal Business Name): PRINTESS JOHN LAWRENCE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PROSPERITY LANE SUITE 100
LOGAN WV
25601
US

IV. Provider business mailing address

300 PROSPERITY LANE SUITE 100
LOGAN WV
25601
US

V. Phone/Fax

Practice location:
  • Phone: 304-831-0073
  • Fax: 304-831-0471
Mailing address:
  • Phone: 304-831-0073
  • Fax: 304-831-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105060
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: