Basic Information
| Provider Information | |||||||||
| NPI: | 1326203589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | TERESA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754686 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 MACK BAYOU LOOP STE 100 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324592606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504161575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | N | Hospitals | General Acute Care Hospital | Children | 2080P0206X | ME111073 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.