Provider Demographics
NPI:1679044135
Name:FELLOWS, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:FELLOWS
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 1:220 N SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-3029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2208
Practice Address - Country:US
Practice Address - Phone:970-641-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0194361163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse