Healthcare Provider Details

I. General information

NPI: 1720766918
Provider Name (Legal Business Name): LARA NGO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/07/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 PLEASANT VALLEY RD STE 201
DIAMOND SPRINGS CA
95619-9260
US

IV. Provider business mailing address

768 PLEASANT VALLEY RD STE 201
DIAMOND SPRINGS CA
95619-9260
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-6290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95263970
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95263970
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95263970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: