Individual
TRACEY LASANE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
5114 DIAMOND DR, LAKE PARK, GA 31636-3087
(850) 739-1233
Mailing address
5114 DIAMOND DR, LAKE PARK, GA 31636-3087
(850) 739-1233
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
053089940
GA
Other
Enumeration date
04/03/2023
Last updated
04/03/2023
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