Provider Demographics
NPI:1225220411
Name:LAWRENCE, MARY JO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 WESTON ROAD RTE 747
Mailing Address - Street 2:
Mailing Address - City:CASANOVA
Mailing Address - State:VA
Mailing Address - Zip Code:20139
Mailing Address - Country:US
Mailing Address - Phone:540-788-4224
Mailing Address - Fax:
Practice Address - Street 1:10696 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4411
Practice Address - Country:US
Practice Address - Phone:703-368-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024134318364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health