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: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COOK PARKWAY SUITE 1
OCEANA WV
24870
US

IV. Provider business mailing address

PO BOX 301
MOUNT GAY WV
25637-0301
US

V. Phone/Fax

Practice location:
  • Phone: 304-886-3997
  • Fax: 855-648-5905
Mailing address:
  • Phone: 304-601-5549
  • Fax: 855-648-5905

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: