Provider Demographics
NPI:1710643622
Name:LAZAR, DOMINIQUE AMBER (NP-C)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:AMBER
Last Name:LAZAR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32255 NORTHWESTERN HWY STE 165
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1505
Mailing Address - Country:US
Mailing Address - Phone:248-735-8272
Mailing Address - Fax:
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 165
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1505
Practice Address - Country:US
Practice Address - Phone:248-735-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329262363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily