Provider Demographics
NPI:1437727096
Name:MCKINNEY, LARA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ANN
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11517 ROLLING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-2032
Mailing Address - Country:US
Mailing Address - Phone:804-514-1006
Mailing Address - Fax:
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1257944163W00000X
VA24179891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherN/A