Provider Demographics
NPI:1376211870
Name:LAZCANO, JESSIE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:MARIE
Last Name:LAZCANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 RIVERMIST DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-5976
Mailing Address - Country:US
Mailing Address - Phone:404-520-0096
Mailing Address - Fax:
Practice Address - Street 1:1541 RIVERMIST DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-5976
Practice Address - Country:US
Practice Address - Phone:404-520-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277986163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse