Provider Demographics
NPI:1073709283
Name:CONNIE LAWRENCE-WILLIS OD PA
Entity Type:Organization
Organization Name:CONNIE LAWRENCE-WILLIS OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE-WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-589-7337
Mailing Address - Street 1:13 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3508
Mailing Address - Country:US
Mailing Address - Phone:772-589-7337
Mailing Address - Fax:772-589-9238
Practice Address - Street 1:2001 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1615
Practice Address - Country:US
Practice Address - Phone:772-589-7337
Practice Address - Fax:772-589-9238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20723Medicare PIN
FLU63462Medicare UPIN