Healthcare Provider Details

I. General information

NPI: 1235040270
Provider Name (Legal Business Name): MICHELLE LEE LARA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W BRASFIELD ST
SMITHVILLE MO
64089-9368
US

IV. Provider business mailing address

209 W BRASFIELD ST
SMITHVILLE MO
64089-9368
US

V. Phone/Fax

Practice location:
  • Phone: 712-899-0486
  • Fax:
Mailing address:
  • Phone: 712-899-0486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number152528
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: