Healthcare Provider Details

I. General information

NPI: 1174881775
Provider Name (Legal Business Name): LARA KATHLEEN DIVINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LARA KATHLEEN JOHNSON

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/31/2021
Certification Date: 05/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BRIDGE ST
TIONESTA PA
16353-9737
US

IV. Provider business mailing address

406 W OAK ST
TITUSVILLE PA
16354-1404
US

V. Phone/Fax

Practice location:
  • Phone: 814-755-3631
  • Fax: 814-755-3633
Mailing address:
  • Phone: 814-755-3631
  • Fax: 814-755-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: