Provider Demographics
NPI:1750194502
Name:MITCHELL BAUDUCCO, LARA (APN)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:
Last Name:MITCHELL BAUDUCCO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 SHELLY LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3119
Mailing Address - Country:US
Mailing Address - Phone:267-242-2149
Mailing Address - Fax:
Practice Address - Street 1:100 ASHURST LN STE 115
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-1202
Practice Address - Country:US
Practice Address - Phone:609-853-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15250200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health