Provider Demographics
NPI:1760538748
Name:LARA, BEVERLY ANN (RPT)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:LARA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HEAGON ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-2330
Mailing Address - Country:US
Mailing Address - Phone:417-681-9006
Mailing Address - Fax:417-681-9006
Practice Address - Street 1:1800 HEAGON ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-2330
Practice Address - Country:US
Practice Address - Phone:417-681-9006
Practice Address - Fax:417-681-9006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist