Provider Demographics
NPI:1114615184
Name:LAWLER, STEPHANIE CLAIRE (CRDH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CLAIRE
Last Name:LAWLER
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12641 MISTY MOUNTAIN DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2104 MASSEY AVE
Practice Address - Street 2:ROOM 2065
Practice Address - City:MAYPORT NAVAL STA
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:904-270-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH18181124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist