Provider Demographics
NPI:1417600438
Name:LIZARDO, REANNA SADE
Entity Type:Individual
Prefix:
First Name:REANNA
Middle Name:SADE
Last Name:LIZARDO
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 1:376 E 8TH ST APT C6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-4258
Mailing Address - Country:US
Mailing Address - Phone:347-554-0691
Mailing Address - Fax:
Practice Address - Street 1:340 KINGSLAND ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1150
Practice Address - Country:US
Practice Address - Phone:973-761-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer