Healthcare Provider Details

I. General information

NPI: 1679881411
Provider Name (Legal Business Name): KATRISHA LAZARRE-LILAVOIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NEPTUNE AVE
WOODMERE NY
11598-1722
US

IV. Provider business mailing address

25 NEPTUNE AVE
WOODMERE NY
11598-1722
US

V. Phone/Fax

Practice location:
  • Phone: 917-776-9917
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013955-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: