Provider Demographics
NPI:1326203589
Name:LAWRENCE, NICOLE TERESA (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:TERESA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4686
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:23 MACK BAYOU LOOP STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2606
Practice Address - Country:US
Practice Address - Phone:850-416-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282NC2000X
FLME1110732080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No282NC2000XHospitalsGeneral Acute Care HospitalChildren