Provider Demographics
NPI:1497729297
Name:LAZARETH, VICTORIA L (NP)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:L
Last Name:LAZARETH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LIVEWELL DR
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6762
Mailing Address - Country:US
Mailing Address - Phone:207-467-8800
Mailing Address - Fax:
Practice Address - Street 1:2 LIVEWELL DR
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6762
Practice Address - Country:US
Practice Address - Phone:207-467-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN224447363LA2200X, 363L00000X
METPP201196363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0375900Medicaid
MA0375900Medicaid
MAUX0129Medicare PIN