Provider Demographics
NPI:1912265117
Name:LAWRENCE, VALERIE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:ELIZABETH
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:2512 HURST DR
Practice Address - Street 2:STE 130
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-258-5900
Practice Address - Fax:217-258-3686
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138867208000000X
NY63210390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program