Provider Demographics
NPI:1073863882
Name:LAWRENCE, LARA LAINE (RN, MNSC, APRN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:LAINE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:RN, MNSC, APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:9840 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6184
Practice Address - Country:US
Practice Address - Phone:817-431-3898
Practice Address - Fax:817-379-1161
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03056 ANP363LP0200X
ARA003056363LP2300X
TXAP139775363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198506758Medicaid