Provider Demographics
NPI:1679917033
Name:JIMENEZ, LAWRENCE CORONEL
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:CORONEL
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508-7003
Mailing Address - Country:US
Mailing Address - Phone:619-944-5641
Mailing Address - Fax:850-452-8978
Practice Address - Street 1:760 EAST AVE BLDG 3911
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508
Practice Address - Country:US
Practice Address - Phone:850-452-8970
Practice Address - Fax:850-452-8978
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-28
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman