Healthcare Provider Details

I. General information

NPI: 1386115178
Provider Name (Legal Business Name): HEIDI JOY LAZOS AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5516 VIRGINIA BEACH BLVD
VIRGINIA BEACH VA
23462-5629
US

IV. Provider business mailing address

5516 VIRGINIA BEACH BLVD
VIRGINIA BEACH VA
23462-5629
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-3969
  • Fax: 757-506-0157
Mailing address:
  • Phone: 757-473-3969
  • Fax: 757-506-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024176874
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: