Provider Demographics
NPI:1225770134
Name:LAWRENCE, FAITH T
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:T
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 WETZEL RD APT 212
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2242
Mailing Address - Country:US
Mailing Address - Phone:315-935-0093
Mailing Address - Fax:
Practice Address - Street 1:4288 WETZEL RD APT 212
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2242
Practice Address - Country:US
Practice Address - Phone:315-935-0093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751437179172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver