Provider Demographics
NPI:1740674530
Name:LARA, NICOLE (AGPCNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N DEVINE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6979
Mailing Address - Country:US
Mailing Address - Phone:360-952-4457
Mailing Address - Fax:
Practice Address - Street 1:650 N DEVINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6979
Practice Address - Country:US
Practice Address - Phone:360-952-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60535353363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care