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General NPI Number Information
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NPI Number | 1164905873
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Entity Type | Individual
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Provider Name | LARA TRINIDAD MANESE NP
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Gender | Female
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Dates
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Enumeration Date | 09/09/2018
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Last Update Date | 09/09/2018
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Provider Practice Location Address
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Address Line | 710 S CENTRAL AVE STE 330
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City | GLENDALE
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State | CA
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Zip | 91204-4647
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Country | US
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Telephone | 818-500-8739
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Fax | 323-500-0957
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Provider Business Mailing Address
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Address Line | 452 VINE ST
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City | GLENDALE
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State | CA
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Zip | 91204-1559
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Country | US
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Telephone | 323-217-9674
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F02180415
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License Number State | CA
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