Provider Demographics
NPI:1518363506
Name:LARA, TANIA
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10812 WINDING RIVER DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-4450
Mailing Address - Country:US
Mailing Address - Phone:402-850-8516
Mailing Address - Fax:
Practice Address - Street 1:4732 S 131ST ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1822
Practice Address - Country:US
Practice Address - Phone:402-697-3923
Practice Address - Fax:402-697-3924
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker