Provider Demographics
NPI:1043931629
Name:LARA, JETTELE JOY D (FNP-C)
Entity Type:Individual
Prefix:
First Name:JETTELE JOY
Middle Name:D
Last Name:LARA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4529
Mailing Address - Country:US
Mailing Address - Phone:626-347-2988
Mailing Address - Fax:
Practice Address - Street 1:1135 S SUNSET AVE STE 401
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3921
Practice Address - Country:US
Practice Address - Phone:626-732-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019623363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics