Provider Demographics
NPI:1659155216
Name:LAWRENCE, AMANDA JOY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
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 1:2649 LAGO OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-9100
Mailing Address - Country:US
Mailing Address - Phone:707-331-4503
Mailing Address - Fax:
Practice Address - Street 1:200 ALBATROSS AVE BLDG N46
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6810
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman