Healthcare Provider Details

I. General information

NPI: 1215631007
Provider Name (Legal Business Name): ROXANA YAMILEHT LAZO GONZALEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 470-956-3860
  • Fax:
Mailing address:
  • Phone:
  • 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: