Provider Demographics
NPI:1619734357
Name:FUNAKOSHI, LARA MIE (CCSH)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:MIE
Last Name:FUNAKOSHI
Suffix:
Gender:F
Credentials:CCSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E GATEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3009
Mailing Address - Country:US
Mailing Address - Phone:801-643-4504
Mailing Address - Fax:801-587-3345
Practice Address - Street 1:375 S CHIPETA WAY STE A200
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84108-1261
Practice Address - Country:US
Practice Address - Phone:801-587-3345
Practice Address - Fax:801-587-3349
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT230174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator