Provider Demographics
NPI:1558618389
Name:LAWRENCE, TARA BRIANNE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BRIANNE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BRIANNE
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100296
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3009
Mailing Address - Country:US
Mailing Address - Phone:352-627-9350
Mailing Address - Fax:352-273-9054
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3009
Practice Address - Country:US
Practice Address - Phone:352-627-9350
Practice Address - Fax:352-273-9054
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013542100Medicaid