Healthcare Provider Details

I. General information

NPI: 1558770800
Provider Name (Legal Business Name): VANESSA LARA PHD, CNS, LDN,LN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 MALLARD CREEK RD STE 300
CHARLOTTE NC
28262-5211
US

IV. Provider business mailing address

3149 BEELER LN
CHARLOTTE NC
28208-6358
US

V. Phone/Fax

Practice location:
  • Phone: 305-613-9141
  • Fax:
Mailing address:
  • Phone: 305-613-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND10461
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX9856
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: