Provider Demographics
NPI:1275865156
Name:COLLAZO, JENNIFER LORI (LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LORI
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 GREENBUSH ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3022
Mailing Address - Country:US
Mailing Address - Phone:607-235-0359
Mailing Address - Fax:
Practice Address - Street 1:92 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3022
Practice Address - Country:US
Practice Address - Phone:607-235-0359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2985581164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse