Provider Demographics
NPI:1407994064
Name:LARA, NANETTE (DOM)
Entity Type:Individual
Prefix:DR
First Name:NANETTE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 CAMINO DE LA SIERRA NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5503
Mailing Address - Country:US
Mailing Address - Phone:505-440-9103
Mailing Address - Fax:505-293-0927
Practice Address - Street 1:3303 CAMINO DE LA SIERRA NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-5503
Practice Address - Country:US
Practice Address - Phone:505-440-9103
Practice Address - Fax:505-293-0927
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM626171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM626OtherSTATE LICENSE NUMBER