Provider Demographics
NPI:1811261522
Name:LAWRENCE, MARY LISA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
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 1:5670 NYS ROUTE 86
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:12997-2015
Mailing Address - Country:US
Mailing Address - Phone:518-637-2306
Mailing Address - Fax:
Practice Address - Street 1:5670 NYS ROUTE 86
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NY
Practice Address - Zip Code:12997-2015
Practice Address - Country:US
Practice Address - Phone:518-637-2306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY498510286344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi