Provider Demographics
NPI:1790344562
Name:MCGLOTHLIN, LARA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ANN
Last Name:MCGLOTHLIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:ANN
Other - Last Name:KELLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2701 PERSIMMON POND RD
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-5057
Mailing Address - Country:US
Mailing Address - Phone:870-378-4335
Mailing Address - Fax:
Practice Address - Street 1:400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-2724
Practice Address - Country:US
Practice Address - Phone:870-631-3538
Practice Address - Fax:870-631-3540
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR120150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120150OtherMEDICAL LICENSE