Provider Demographics
NPI:1396023040
Name:LARA, CANDICE (LPN)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60179
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-0179
Mailing Address - Country:US
Mailing Address - Phone:347-359-0602
Mailing Address - Fax:
Practice Address - Street 1:316 BEACH 65TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11692-1425
Practice Address - Country:US
Practice Address - Phone:347-359-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298848-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse