Healthcare Provider Details

I. General information

NPI: 1912351347
Provider Name (Legal Business Name): DANIELLE RAFFAELLA LAZZARA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12455 BROADWELL RD STE 102-103
MILTON GA
30004-6315
US

IV. Provider business mailing address

12455 BROADWELL RD STE 102-103
MILTON GA
30004-6315
US

V. Phone/Fax

Practice location:
  • Phone: 770-375-6197
  • Fax: 770-215-7577
Mailing address:
  • Phone: 770-375-6197
  • Fax: 706-253-3223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number87864
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number87864
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: