Provider Demographics
NPI:1033479308
Name:LANZA, NICOLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:LANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3142 MORLEY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1948
Mailing Address - Country:US
Mailing Address - Phone:646-354-0940
Mailing Address - Fax:
Practice Address - Street 1:3142 MORLEY AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:646-354-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY550415111174400000X
NY550381111390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program