Provider Demographics
NPI:1073277109
Name:SARDEA, LARA JANE GONGOB (BSN,RN,MSN)
Entity Type:Individual
Prefix:
First Name:LARA JANE
Middle Name:GONGOB
Last Name:SARDEA
Suffix:
Gender:F
Credentials:BSN,RN,MSN
Other - Prefix:
Other - First Name:LARA JANE
Other - Middle Name:JORDAS
Other - Last Name:GONGOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN,RN,MSN
Mailing Address - Street 1:5423 83RD ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5423 83RD ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4723
Practice Address - Country:US
Practice Address - Phone:332-234-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY824423163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse