Provider Demographics
NPI:1154412401
Name:LAWRENCE, MARISA (MD PC)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FY RD NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1607
Mailing Address - Country:US
Mailing Address - Phone:404-303-7004
Mailing Address - Fax:404-303-7020
Practice Address - Street 1:980 JOHNSON FY RD NE STE 110
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1607
Practice Address - Country:US
Practice Address - Phone:404-303-7004
Practice Address - Fax:404-303-7020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA582261832174400000X
GA38839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582261832OtherTAX ID