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General NPI Number Information
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NPI Number | 1265961114
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Entity Type | Individual
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Provider Name | JEANETTE LARA DO
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Gender | Female
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Dates
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Enumeration Date | 06/05/2017
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Last Update Date | 12/11/2020
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Provider Practice Location Address
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Address Line | 204 ANGELINA BLVD
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City | CHAPARRAL
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State | NM
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Zip | 88081-7558
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Country | US
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Telephone | 758-248-1005
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Fax | 575-824-8101
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Provider Business Mailing Address
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Address Line | 204 ANGELINA BLVD
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City | CHAPARRAL
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State | NM
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Zip | 88081-7558
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Country | US
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Telephone | 758-248-1005
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Fax | 575-824-8101
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R-25-2017
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A-2410-20
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License Number State | NM
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