Healthcare Provider Details

I. General information

NPI: 1265281109
Provider Name (Legal Business Name): SAMANTHA GRACE LAZARUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

IV. Provider business mailing address

905 TABB LAKES DR
YORKTOWN VA
23693-4403
US

V. Phone/Fax

Practice location:
  • Phone: 301-540-5246
  • Fax:
Mailing address:
  • Phone: 757-376-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: