Healthcare Provider Details

I. General information

NPI: 1962280164
Provider Name (Legal Business Name): JESSICA LAZIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LYNN JESSICA

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 BRENDAN AVE
MASSAPEQUA NY
11758-6124
US

IV. Provider business mailing address

339 BRENDAN AVE
MASSAPEQUA NY
11758-6124
US

V. Phone/Fax

Practice location:
  • Phone: 516-652-5916
  • Fax:
Mailing address:
  • Phone: 163-133-8929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2531470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: