Healthcare Provider Details

I. General information

NPI: 1083226724
Provider Name (Legal Business Name): JOACCY LAZO REYES ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 SE 15TH AVE
CAPE CORAL FL
33990-4659
US

IV. Provider business mailing address

3900 BROADWAY STE B-3
FORT MYERS FL
33901-8193
US

V. Phone/Fax

Practice location:
  • Phone: 239-888-2980
  • Fax:
Mailing address:
  • Phone: 239-590-8571
  • Fax: 239-590-8571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: