Provider Demographics
NPI:1346816188
Name:LAWRENCE, CANDACE TIFFANY
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:TIFFANY
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 1:1111 E 72ND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5456
Mailing Address - Country:US
Mailing Address - Phone:917-488-7764
Mailing Address - Fax:
Practice Address - Street 1:1111 E 72ND ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5456
Practice Address - Country:US
Practice Address - Phone:917-488-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY770340-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse