Healthcare Provider Details

I. General information

NPI: 1497729297
Provider Name (Legal Business Name): VICTORIA L LAZARETH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD STE 203
SOUTH PORTLAND ME
04106-2327
US

IV. Provider business mailing address

100 GANNETT DR STE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-523-3900
  • Fax:
Mailing address:
  • Phone: 207-347-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN224447
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN224447
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP201196
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: