Provider Demographics
NPI:1063475440
Name:LAWRENCE, MARY KATHERINE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:APRN
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Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:220 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3208
Practice Address - Country:US
Practice Address - Phone:662-290-3150
Practice Address - Fax:662-290-3160
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-01-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS672602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03338302Medicaid
MS03338302Medicaid
MSQ49576Medicare UPIN