Provider Demographics
NPI:1205388097
Name:COLLAZO, JUAN (LPN)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-4917
Mailing Address - Country:US
Mailing Address - Phone:585-532-1255
Mailing Address - Fax:
Practice Address - Street 1:471 BERNARD ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4917
Practice Address - Country:US
Practice Address - Phone:585-532-1255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326926164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse