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General NPI Number Information
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NPI Number | 1356949978
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Entity Type | Individual
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Provider Name | AMANDA MICHELLE LARA LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 10/15/2020
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Last Update Date | 10/15/2020
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Provider Practice Location Address
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Address Line | 11100 NW 27TH ST
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City | DORAL
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State | FL
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Zip | 33172-5001
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Country | US
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Telephone | 305-591-0020
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Fax | 305-591-9251
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Provider Business Mailing Address
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Address Line | 2401 OVERBROOK ST APT 206
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City | MIAMI
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State | FL
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Zip | 33133-3197
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Country | US
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Telephone | 786-255-0002
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL4328
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License Number State | FL
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