Provider Demographics
NPI:1104216613
Name:LANZA, LAURIE (MA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:LANZA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 S PHOEBE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-9275
Mailing Address - Country:US
Mailing Address - Phone:360-600-4825
Mailing Address - Fax:
Practice Address - Street 1:414 PIONEER ST STE 101
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-4512
Practice Address - Country:US
Practice Address - Phone:360-600-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60444960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist