Healthcare Provider Details

I. General information

NPI: 1053727420
Provider Name (Legal Business Name): LARA SHIPLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 FREMONT BLVD SUITE 210B
SEASIDE CA
93955-5700
US

IV. Provider business mailing address

195 AVIATION WAY SUITE 200
WATSONVILLE CA
95076-2053
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-0222
  • Fax: 831-707-2777
Mailing address:
  • Phone: 831-728-8250
  • Fax: 831-707-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: