Healthcare Provider Details

I. General information

NPI: 1124758750
Provider Name (Legal Business Name): LARA JOY SULTAN FNTP, CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SPUR RANCH AVE
NORTH LAS VEGAS NV
89032-8108
US

IV. Provider business mailing address

PO BOX 8626
HOT SPRINGS VILLAGE AR
71910-8626
US

V. Phone/Fax

Practice location:
  • Phone: 760-518-9431
  • Fax:
Mailing address:
  • Phone: 760-518-9431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number3305
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: