Healthcare Provider Details

I. General information

NPI: 1558148353
Provider Name (Legal Business Name): BERTA JAIME LARA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

851 9TH ST
ORANGE COVE CA
93646-2307
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 559-672-0452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07230350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: