Healthcare Provider Details

I. General information

NPI: 1033591789
Provider Name (Legal Business Name): KATHERINE LAZET DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 STATE ST
BOSTON MA
02109-1827
US

IV. Provider business mailing address

3304 RUSSELL BLVD APT B
SAINT LOUIS MO
63104-1554
US

V. Phone/Fax

Practice location:
  • Phone: 906-869-2836
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005302A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101021889
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05214
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4666
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023040087
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.161926
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: