Healthcare Provider Details

I. General information

NPI: 1407994064
Provider Name (Legal Business Name): NANETTE LARA D.O.M
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 CAMINO DE LA SIERRA NE
ALBUQUERQUE NM
87111-5503
US

IV. Provider business mailing address

3303 CAMINO DE LA SIERRA NE
ALBUQUERQUE NM
87111-5503
US

V. Phone/Fax

Practice location:
  • Phone: 505-440-9103
  • Fax: 505-293-0927
Mailing address:
  • Phone: 505-440-9103
  • Fax: 505-293-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number626
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: