Healthcare Provider Details

I. General information

NPI: 1629056833
Provider Name (Legal Business Name): DONNA LANZA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 ROUTE 25A BLDG 15
MILLER PLACE NY
11764-2643
US

IV. Provider business mailing address

691 ROUTE 25A BLDG 15
MILLER PLACE NY
11764-2643
US

V. Phone/Fax

Practice location:
  • Phone: 631-332-1779
  • Fax: 631-982-5650
Mailing address:
  • Phone: 631-332-1779
  • Fax: 631-982-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14510
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: