Provider Demographics
NPI:1821298118
Name:LAWRENCE, ANGELENE MICHAELE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELENE
Middle Name:MICHAELE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELENE
Other - Middle Name:MICHAELE
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1233 EDGEWATER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV117592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV11759OtherSTATE LICENSE
11976606OtherCAQH