Healthcare Provider Details

I. General information

NPI: 1255952636
Provider Name (Legal Business Name): LAIZA SOUZA TANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E ROLLINS ST
ORLANDO FL
32803
US

IV. Provider business mailing address

140 MANDOLIN DR
WINTER HAVEN FL
33884-3580
US

V. Phone/Fax

Practice location:
  • Phone: 855-724-5411
  • Fax:
Mailing address:
  • Phone: 727-710-4072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: