Provider Demographics
NPI:1730791583
Name:LASKY, CLARISSA LAUREN
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:LAUREN
Last Name:LASKY
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 1:431 PACIFIC AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-7706
Mailing Address - Country:US
Mailing Address - Phone:262-389-5636
Mailing Address - Fax:
Practice Address - Street 1:2447 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7815
Practice Address - Country:US
Practice Address - Phone:707-544-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program