Provider Demographics
NPI:1447618970
Name:CANZONERI, LACY LAKAY
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:LAKAY
Last Name:CANZONERI
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 1:16143 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1951
Mailing Address - Country:US
Mailing Address - Phone:313-999-8142
Mailing Address - Fax:
Practice Address - Street 1:16143 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1951
Practice Address - Country:US
Practice Address - Phone:313-999-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Z00000X
MIC525488488098247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other