Provider Demographics
NPI:1255838447
Name:LAZAR, STACEY ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:LAZAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:ZINOWICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-444-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner