Provider Demographics
NPI:1659036259
Name:LAZZARA, DENICE
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:
Last Name:LAZZARA
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 1:1320 NE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-1432
Mailing Address - Country:US
Mailing Address - Phone:503-415-0782
Mailing Address - Fax:
Practice Address - Street 1:1320 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-1432
Practice Address - Country:US
Practice Address - Phone:503-415-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60700891183700000X
WA60039723251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60039723OtherNURSING ASSISTANT CERTIFICATION
WA60700891OtherPHARMACY TECHNICIAN