1487642245 NPI number — DR. GRACE ANNE LAWRENCE PHARMD, CGP

Table of content: DR. GRACE ANNE LAWRENCE PHARMD, CGP (NPI 1487642245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487642245 NPI number — DR. GRACE ANNE LAWRENCE PHARMD, CGP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
GRACE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, CGP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487642245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2555 E PLATEAU DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-7562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-890-6811
Provider Business Mailing Address Fax Number:
208-424-8903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10464 GARVERDALE CT
Provider Second Line Business Practice Location Address:
SUITE 706
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-5410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-323-1259
Provider Business Practice Location Address Fax Number:
208-323-5666
Provider Enumeration Date:
10/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  P5050 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1835P1200X , with the licence number: P5050 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1835P1300X , with the licence number: P5050 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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