Provider Demographics
NPI:1104433820
Name:LACLAIR, JENNIFER BLAZE (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BLAZE
Last Name:LACLAIR
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24874 COUNTY ROUTE 16
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3107
Mailing Address - Country:US
Mailing Address - Phone:315-767-3387
Mailing Address - Fax:
Practice Address - Street 1:26561 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1749
Practice Address - Country:US
Practice Address - Phone:315-782-7246
Practice Address - Fax:315-782-7247
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily