Provider Demographics
NPI:1255705265
Name:LAURENCE, CLARA (LAC)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:LAURENCE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11021 GURLEY LN
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-9584
Mailing Address - Country:US
Mailing Address - Phone:707-813-0105
Mailing Address - Fax:
Practice Address - Street 1:100 E MANZANITA ST
Practice Address - Street 2:SUITE C
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3054
Practice Address - Country:US
Practice Address - Phone:707-813-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16702171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist