Basic Information
Provider Information | |||||||||
NPI: | 1306922562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAWRENCE | ||||||||
FirstName: | CLARISSA | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAWRENCE | ||||||||
OtherFirstName: | LEESA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1020 TERRACE DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MARION | ||||||||
State: | VA | ||||||||
PostalCode: | 243544392 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2767838183 | ||||||||
FaxNumber: | 2767829267 | ||||||||
Practice Location | |||||||||
Address1: | 1702 MEDICAL PARK DR W | ||||||||
Address2: |   | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278932705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522437944 | ||||||||
FaxNumber: | 2522436097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101262369 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1306922562 | 05 | VA |   | MEDICAID | 8951212 | 05 | NC |   | MEDICAID |