Provider Demographics
NPI:1598223356
Name:BACERIO LARA, MARIELA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:BACERIO LARA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 US HIGHWAY 27 S
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-9755
Mailing Address - Country:US
Mailing Address - Phone:863-358-0500
Mailing Address - Fax:
Practice Address - Street 1:2778 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-9755
Practice Address - Country:US
Practice Address - Phone:863-358-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2025-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217589163W00000X
FL11038482363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse