Provider Demographics
NPI:1851971683
Name:LAFAYETTE, AMY (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LAFAYETTE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 BEARTOWN LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7094
Mailing Address - Country:US
Mailing Address - Phone:323-823-6786
Mailing Address - Fax:
Practice Address - Street 1:7400 PYRAMID PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-1317
Practice Address - Country:US
Practice Address - Phone:323-823-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0134026171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist