Provider Demographics
NPI:1467578047
Name:LARA, MELLANI MALLARI (LVN)
Entity Type:Individual
Prefix:
First Name:MELLANI
Middle Name:MALLARI
Last Name:LARA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53941 CALLE SANBORN
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-3139
Mailing Address - Country:US
Mailing Address - Phone:760-218-0196
Mailing Address - Fax:
Practice Address - Street 1:81557 DR CARREON BLVD STE C9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5562
Practice Address - Country:US
Practice Address - Phone:760-391-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197993164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse