1841649480 NPI number — CATHERINE ROSE LARA NURSE PRACTITIONER

Table of content: CATHERINE ROSE LARA NURSE PRACTITIONER (NPI 1841649480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841649480 NPI number — CATHERINE ROSE LARA NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARA
Provider First Name:
CATHERINE
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841649480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9401 S PULASKI RD
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
EVERGREEN PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60805-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-359-1928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 W 203RD ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA FIELDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60461-1185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-679-2670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209014104 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)