Healthcare Provider Details

I. General information

NPI: 1588474373
Provider Name (Legal Business Name): LARA MACHELLE LEROY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LARA WILLIAMS RN

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W MOHAVE RD
PARKER AZ
85344-6349
US

IV. Provider business mailing address

1200 W MOHAVE RD
PARKER AZ
85344-6349
US

V. Phone/Fax

Practice location:
  • Phone: 760-646-4428
  • Fax:
Mailing address:
  • Phone: 760-646-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number223752
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: