Healthcare Provider Details

I. General information

NPI: 1033479308
Provider Name (Legal Business Name): MS. NICOLE LANZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 MORLEY AVENUE
STATEN ISLAND NY
10306
US

IV. Provider business mailing address

3142 MORLEY AVE
STATEN ISLAND NY
10306-1948
US

V. Phone/Fax

Practice location:
  • Phone: 646-354-0940
  • Fax:
Mailing address:
  • Phone: 646-354-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number550381111
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number550415111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: