Healthcare Provider Details

I. General information

NPI: 1417656992
Provider Name (Legal Business Name): GISSELLE LARA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10251 ARTESIA BLVD
BELLFLOWER CA
90706-6719
US

IV. Provider business mailing address

234 E BADILLO ST
COVINA CA
91723-2115
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-8681
  • Fax: 562-866-5198
Mailing address:
  • Phone: 626-915-9992
  • Fax: 626-410-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: