Healthcare Provider Details

I. General information

NPI: 1962269134
Provider Name (Legal Business Name): JESSICA LAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 10/01/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 MIRAMAR PKWY
MIRAMAR FL
33023-3970
US

IV. Provider business mailing address

6151 MIRAMAR PKWY
MIRAMAR FL
33023-3970
US

V. Phone/Fax

Practice location:
  • Phone: 954-603-5100
  • Fax:
Mailing address:
  • Phone: 954-603-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11031050
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: