Provider Demographics
NPI:1134342553
Name:KALUSH, LARA R
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:R
Last Name:KALUSH
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 1:2800 UNIVERSITY BLVD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-3321
Mailing Address - Country:US
Mailing Address - Phone:904-256-8080
Mailing Address - Fax:
Practice Address - Street 1:5491 DOLPHIN POINT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211
Practice Address - Country:US
Practice Address - Phone:303-807-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO118940363L00000X
FL11011666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner