Healthcare Provider Details

I. General information

NPI: 1366307860
Provider Name (Legal Business Name): MRS. LARA NICOLE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11590 W BERNARDO CT STE 120
SAN DIEGO CA
92127-1624
US

IV. Provider business mailing address

12766 SHADOWLINE ST
POWAY CA
92064-6416
US

V. Phone/Fax

Practice location:
  • Phone: 619-733-6414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPCC21210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: