Provider Demographics
NPI:1053690420
Name:LAWRENCE, MICKY JAYNES
Entity type:Individual
Prefix:MRS
First Name:MICKY
Middle Name:JAYNES
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICKY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:52 JOURNEAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2233
Mailing Address - Country:US
Mailing Address - Phone:646-355-5075
Mailing Address - Fax:
Practice Address - Street 1:52 JOURNEAY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2233
Practice Address - Country:US
Practice Address - Phone:646-355-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY757926163W00000X
NY305513-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse