Provider Demographics
NPI:1962280164
Name:LAZIO, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAZIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:JESSICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:339 BRENDAN AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6124
Mailing Address - Country:US
Mailing Address - Phone:163-133-8929
Mailing Address - Fax:
Practice Address - Street 1:339 BRENDAN AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6124
Practice Address - Country:US
Practice Address - Phone:516-652-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2531470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist