Provider Demographics
NPI:1306922562
Name:LAWRENCE, CLARISSA G (MD)
Entity type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:G
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LEESA
Other - Middle Name:M
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1020 TERRACE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4392
Mailing Address - Country:US
Mailing Address - Phone:276-783-8183
Mailing Address - Fax:276-782-9267
Practice Address - Street 1:1702 MEDICAL PARK DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2705
Practice Address - Country:US
Practice Address - Phone:252-243-7944
Practice Address - Fax:252-243-6097
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1306922562Medicaid
NC8951212Medicaid
G00793Medicare UPIN