Healthcare Provider Details

I. General information

NPI: 1043893035
Provider Name (Legal Business Name): JACQUELINE ARLENE LAZARUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8060 NW 96TH TER APT 306
TAMARAC FL
33321-1360
US

IV. Provider business mailing address

8060 NW 96TH TER APT 306
TAMARAC FL
33321-1360
US

V. Phone/Fax

Practice location:
  • Phone: 754-264-5807
  • Fax:
Mailing address:
  • Phone: 754-264-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9283554
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: