Provider Demographics
NPI:1396336459
Name:SUDIK, LARA DUPRE (FNP-C)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:DUPRE
Last Name:SUDIK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HUISACHE ST
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:TX
Mailing Address - Zip Code:77962-8414
Mailing Address - Country:US
Mailing Address - Phone:361-649-4674
Mailing Address - Fax:
Practice Address - Street 1:910 HUISACHE ST
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:TX
Practice Address - Zip Code:77962-8414
Practice Address - Country:US
Practice Address - Phone:361-649-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1024878363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily