Provider Demographics
NPI:1710357926
Name:WEST, LARESA D (NP)
Entity Type:Individual
Prefix:
First Name:LARESA
Middle Name:D
Last Name:WEST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:540 CHARTER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4892
Mailing Address - Country:US
Mailing Address - Phone:478-471-0089
Mailing Address - Fax:478-471-0708
Practice Address - Street 1:540 CHARTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4892
Practice Address - Country:US
Practice Address - Phone:478-471-0089
Practice Address - Fax:478-471-0708
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN162702NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily