1548587272 NPI number — LARA ELLEN KING-FREDERICK N.P.

Table of content: LARA ELLEN KING-FREDERICK N.P. (NPI 1548587272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548587272 NPI number — LARA ELLEN KING-FREDERICK N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING-FREDERICK
Provider First Name:
LARA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREDERICK
Provider Other First Name:
LARA
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RNC, MS, FNP, ET
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548587272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16061 BEAR VALLEY RD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
HESPERIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92345-1730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-948-0980
Provider Business Mailing Address Fax Number:
760-948-3510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16061 BEAR VALLEY RD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345-1730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-948-0980
Provider Business Practice Location Address Fax Number:
760-948-3510
Provider Enumeration Date:
04/20/2010

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:  10643 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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