Provider Demographics
NPI:1962689794
Name:KIERLIN, LARA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:MARIA
Last Name:KIERLIN
Suffix:
Gender:F
Credentials:MD
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 363
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-0363
Mailing Address - Country:US
Mailing Address - Phone:310-909-3738
Mailing Address - Fax:888-980-6071
Practice Address - Street 1:12826 SE 40TH LN STE 203
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-4276
Practice Address - Country:US
Practice Address - Phone:425-610-7705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153794207R00000X, 2084S0012X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641583Medicaid
OR500655829Medicaid
OR500641583Medicaid