Provider Demographics
NPI:1629473343
Name:LAWRENCE, VISHAUN (FNP)
Entity Type:Individual
Prefix:
First Name:VISHAUN
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 1:5445 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9611
Mailing Address - Country:US
Mailing Address - Phone:319-372-6530
Mailing Address - Fax:
Practice Address - Street 1:5445 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9611
Practice Address - Country:US
Practice Address - Phone:319-372-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA145966363L00000X
IL209011761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400177145Medicare PIN