Provider Demographics
NPI:1558770800
Name:LARA, VANESSA (PHD, CNS, LDN,LN)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:PHD, CNS, LDN,LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 BEELER LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-6358
Mailing Address - Country:US
Mailing Address - Phone:305-613-9141
Mailing Address - Fax:
Practice Address - Street 1:10400 MALLARD CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5211
Practice Address - Country:US
Practice Address - Phone:305-613-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL39192255A2300X
MDDX9856133V00000X
FLND10461133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No133N00000XDietary & Nutritional Service ProvidersNutritionist