Healthcare Provider Details

I. General information

NPI: 1396435756
Provider Name (Legal Business Name): CAITLIN LAZURICK GANN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 DAN PROCTOR DR STE 140
SAINT MARYS GA
31558-3812
US

IV. Provider business mailing address

2040 DAN PROCTOR DR STE 140
SAINT MARYS GA
31558-3812
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-6200
  • Fax: 912-882-6411
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113304
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: