Provider Demographics
NPI:1184221798
Name:HANSEN, LARAE JEAN (MSN, PNP)
Entity Type:Individual
Prefix:
First Name:LARAE
Middle Name:JEAN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MSN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 REDONDO ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3814
Mailing Address - Country:US
Mailing Address - Phone:805-452-8436
Mailing Address - Fax:
Practice Address - Street 1:7805 REDONDO ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-3814
Practice Address - Country:US
Practice Address - Phone:805-452-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015281363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95015281OtherNP LICENSE