Healthcare Provider Details

I. General information

NPI: 1710357926
Provider Name (Legal Business Name): LARESA D WEST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 CHARTER BLVD SUITE 100
MACON GA
31210-4892
US

IV. Provider business mailing address

540 CHARTER BLVD SUITE 100
MACON GA
31210-4892
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-0089
  • Fax: 478-471-0708
Mailing address:
  • Phone: 478-471-0089
  • Fax: 478-471-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN162702NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: