Provider Demographics
NPI:1124566658
Name:KERBO, LAZANDA
Entity Type:Individual
Prefix:
First Name:LAZANDA
Middle Name:
Last Name:KERBO
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 1:1336 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-3762
Mailing Address - Country:US
Mailing Address - Phone:229-421-3212
Mailing Address - Fax:
Practice Address - Street 1:1336 YOUNG ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-3762
Practice Address - Country:US
Practice Address - Phone:229-421-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home