Provider Demographics
NPI:1124773247
Name:LAWRENCE, TA TANISHA
Entity type:Individual
Prefix:MRS
First Name:TA
Middle Name:TANISHA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 INGERSOLL DR STE 5
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-6040
Mailing Address - Country:US
Mailing Address - Phone:706-289-0800
Mailing Address - Fax:334-326-4988
Practice Address - Street 1:1002 INGERSOLL DR STE 5
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-6040
Practice Address - Country:US
Practice Address - Phone:706-289-0800
Practice Address - Fax:334-326-4988
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier