Provider Demographics
NPI:1255667077
Name:LAGAZO-GUIA, JACQUELINE (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LAGAZO-GUIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 EAST 77TH STREET
Mailing Address - Street 2:9 BLACK HALL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1851
Mailing Address - Country:US
Mailing Address - Phone:212-434-6575
Mailing Address - Fax:212-434-2595
Practice Address - Street 1:130 EAST 77TH STREET
Practice Address - Street 2:9 BLACK HALL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1851
Practice Address - Country:US
Practice Address - Phone:212-434-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335864-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily