Provider Demographics
NPI:1548587272
Name:KING-FREDERICK, LARA ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ELLEN
Last Name:KING-FREDERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:ELLEN
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RNC, MS, FNP, ET
Mailing Address - Street 1:16061 BEAR VALLEY RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1730
Mailing Address - Country:US
Mailing Address - Phone:760-948-0980
Mailing Address - Fax:760-948-3510
Practice Address - Street 1:16061 BEAR VALLEY RD
Practice Address - Street 2:SUITE 7
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1730
Practice Address - Country:US
Practice Address - Phone:760-948-0980
Practice Address - Fax:760-948-3510
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily