Healthcare Provider Details

I. General information

NPI: 1508580580
Provider Name (Legal Business Name): HALEY LARA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10909 N PERRYVILLE RD
SURPRISE AZ
85388-9713
US

IV. Provider business mailing address

15608 W ACAPULCO LN
SURPRISE AZ
85379-6225
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-7000
  • Fax:
Mailing address:
  • Phone: 210-978-6909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number326252
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: