Provider Demographics
NPI:1700757184
Name:LAWRENCE, BREANNA (CSFA)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 4 FORKS RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7252
Mailing Address - Country:US
Mailing Address - Phone:757-525-0158
Mailing Address - Fax:
Practice Address - Street 1:3050 HALSTEAD BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-690-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC187178208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery