Provider Demographics
NPI:1689283483
Name:LARA MALDONADO, FERNANDA MARIA
Entity Type:Individual
Prefix:
First Name:FERNANDA
Middle Name:MARIA
Last Name:LARA MALDONADO
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 1:175 W B ST STE D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4575
Mailing Address - Country:US
Mailing Address - Phone:541-762-1971
Mailing Address - Fax:541-762-1974
Practice Address - Street 1:175 W B ST STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4575
Practice Address - Country:US
Practice Address - Phone:541-762-1971
Practice Address - Fax:541-762-1974
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201808478CNA376K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide