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General NPI Number Information
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NPI Number | 1811534472
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Entity Type | Individual
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Provider Name | LAWRENCE SELF
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Gender | Male
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Dates
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Enumeration Date | 12/03/2019
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 19150 HIGHWAY 61 N
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City | LYON
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State | MS
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Zip | 38645-9779
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Country | US
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Telephone | 662-902-4614
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Fax |
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Provider Business Mailing Address
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Address Line | 19150 HIGHWAY 61 N
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City | LYON
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State | MS
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Zip | 38645-9779
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number | 800040716
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License Number State | MS
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