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General NPI Number Information
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NPI Number | 1104433820
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Entity Type | Individual
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Provider Name | JENNIFER BLAZE LACLAIR FNP-C
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Gender | Female
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Dates
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Enumeration Date | 09/27/2020
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Last Update Date | 09/28/2020
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Provider Practice Location Address
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Address Line | 26561 STATE ROUTE 3
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City | WATERTOWN
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State | NY
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Zip | 13601-1749
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Country | US
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Telephone | 315-782-7246
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Fax | 315-782-7247
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Provider Business Mailing Address
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Address Line | 24874 COUNTY ROUTE 16
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City | EVANS MILLS
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State | NY
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Zip | 13637-3107
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Country | US
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Telephone | 315-767-3387
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 346485
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License Number State | NY
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