Provider Demographics
NPI:1174735542
Name:LAWRENCE, GINA MARCELLE (LMT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARCELLE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62968 O B RILEY RD BLDG E2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-9442
Mailing Address - Country:US
Mailing Address - Phone:541-815-5227
Mailing Address - Fax:
Practice Address - Street 1:62968 O B RILEY RD BLDG E2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-9442
Practice Address - Country:US
Practice Address - Phone:541-815-5227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist