Provider Demographics
NPI:1588766018
Name:LAWRENCE-WILLIS, CONNIE (OD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:LAWRENCE-WILLIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1615
Mailing Address - Country:US
Mailing Address - Phone:772-589-7337
Mailing Address - Fax:772-589-0707
Practice Address - Street 1:2001 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1615
Practice Address - Country:US
Practice Address - Phone:772-589-7337
Practice Address - Fax:772-589-0707
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL711203OtherEYEMED PROVIDER ID
FL20723Medicare ID - Type Unspecified
FLU63462Medicare UPIN