Healthcare Provider Details

I. General information

NPI: 1063501260
Provider Name (Legal Business Name): KRISTIE R LAZZARA DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MACON AVE
STATEN ISLAND NY
10312-2014
US

IV. Provider business mailing address

105 MACON AVE
STATEN ISLAND NY
10312-2014
US

V. Phone/Fax

Practice location:
  • Phone: 718-885-7133
  • Fax:
Mailing address:
  • Phone: 718-885-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number70011039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: