Provider Demographics
NPI:1104197292
Name:LAWRENCE, JIMMY LYNN
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:LYNN
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 WASHINGTON ST SW
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-9523
Mailing Address - Country:US
Mailing Address - Phone:540-231-5690
Mailing Address - Fax:540-231-7335
Practice Address - Street 1:675 WASHINGTON ST SW
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-9523
Practice Address - Country:US
Practice Address - Phone:540-231-5690
Practice Address - Fax:540-231-7335
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1260003132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer