Provider Demographics
NPI:1710132972
Name:THE PHYSICIAN & MIDWIFE COLLABORATIVE PRACTICE PC
Entity Type:Organization
Organization Name:THE PHYSICIAN & MIDWIFE COLLABORATIVE PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE MIDWIFE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZZARO
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:716-912-2945
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-370-4300
Mailing Address - Fax:703-370-0044
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-370-4300
Practice Address - Fax:703-370-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169729363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty