Provider Demographics
NPI:1255952636
Name:SOUZA TANNER, LAIZA
Entity type:Individual
Prefix:
First Name:LAIZA
Middle Name:
Last Name:SOUZA TANNER
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 1:140 MANDOLIN DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3580
Mailing Address - Country:US
Mailing Address - Phone:727-710-4072
Mailing Address - Fax:
Practice Address - Street 1:500 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:855-724-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician