Provider Demographics
NPI:1073004693
Name:LAZAGA, SYBERT ANNE
Entity Type:Individual
Prefix:
First Name:SYBERT ANNE
Middle Name:
Last Name:LAZAGA
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 1:12272 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4227
Mailing Address - Country:US
Mailing Address - Phone:954-913-0839
Mailing Address - Fax:
Practice Address - Street 1:607 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-1124
Practice Address - Country:US
Practice Address - Phone:254-729-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1278587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL220-780-89-861-0OtherDRIVER'S LICENSE