Healthcare Provider Details

I. General information

NPI: 1619251147
Provider Name (Legal Business Name): GLENNYN WONG LARA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLENNYN WONG LARA RN

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 01/25/2026
Certification Date: 01/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 W 20TH AVE STE 212
HIALEAH FL
33016-1812
US

IV. Provider business mailing address

4300 NW 173RD DR
MIAMI GARDENS FL
33055-3706
US

V. Phone/Fax

Practice location:
  • Phone: 305-504-2117
  • Fax: 305-504-2117
Mailing address:
  • Phone: 786-302-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9614896
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: