Provider Demographics
NPI:1790089928
Name:DE LA VARA, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:DE LA VARA
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:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0634
Mailing Address - Country:US
Mailing Address - Phone:928-627-4525
Mailing Address - Fax:
Practice Address - Street 1:725 E. MAIN ST.
Practice Address - Street 2:SUITE 1C
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350-0634
Practice Address - Country:US
Practice Address - Phone:928-627-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2571I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician