Provider Demographics
NPI:1427514470
Name:LUCRIDA, LIZLYN ROSE LAO (NP)
Entity type:Individual
Prefix:
First Name:LIZLYN ROSE
Middle Name:LAO
Last Name:LUCRIDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 COYLE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 275
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1263
Practice Address - Country:US
Practice Address - Phone:909-823-8000
Practice Address - Fax:909-823-8088
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty