Provider Demographics
NPI:1063420164
Name:LAWRENCE, LYNNAE SUSAN (MD)
Entity type:Individual
Prefix:
First Name:LYNNAE
Middle Name:SUSAN
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 1:1134 KUKULU ST APT 606
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4514
Mailing Address - Country:US
Mailing Address - Phone:406-702-0686
Mailing Address - Fax:
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:808-433-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5271207R00000X
HI20222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD27921Medicaid
AKH06348Medicare UPIN
AK8HE990Medicare ID - Type UnspecifiedMEDICARE ID