Provider Demographics
NPI:1962642058
Name:LARA, REGINA (LPN)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6068 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-9034
Mailing Address - Country:US
Mailing Address - Phone:262-767-0691
Mailing Address - Fax:
Practice Address - Street 1:6068 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-9034
Practice Address - Country:US
Practice Address - Phone:262-767-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310147-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse