Provider Demographics
NPI:1912171406
Name:LARA, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9338 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7613
Mailing Address - Country:US
Mailing Address - Phone:414-617-0710
Mailing Address - Fax:
Practice Address - Street 1:9338 S 48TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7613
Practice Address - Country:US
Practice Address - Phone:414-617-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38202800Medicaid