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General NPI Number Information
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NPI Number | 1730497884
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Entity Type | Individual
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Provider Name | KIMBERKY LANZA COTA/L
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Gender | Female
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 09/22/2010
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Provider Practice Location Address
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Address Line | 1 BRANDYWINE DR
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City | DEER PARK
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State | NY
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Zip | 11729-5721
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Country | US
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Telephone | 631-362-0081
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Fax |
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Provider Business Mailing Address
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Address Line | 48 BURNEY BLVD
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City | MASTIC
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State | NY
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Zip | 11950-1304
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Country | US
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Telephone | 631-281-1517
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 007357-1
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License Number State | NY
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