Healthcare Provider Details

I. General information

NPI: 1821309618
Provider Name (Legal Business Name): LARA NICOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3001
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-0296
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0462
  • Fax: 352-265-0443
Mailing address:
  • Phone: 352-265-0462
  • Fax: 352-265-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.057377
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME127080
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: