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General NPI Number Information
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NPI Number | 1609751338
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Entity Type | Individual
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Provider Name | LARA MICHAELA VANCE PTA
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Gender | Female
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Dates
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Enumeration Date | 08/11/2025
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Last Update Date | 08/11/2025
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Provider Practice Location Address
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Address Line | 21760 FL-54 #102
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City | LUTZ
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State | FL
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Zip | 33549
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Country | US
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Telephone | 813-252-0561
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Fax |
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Provider Business Mailing Address
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Address Line | 8435 PANAHAN DR
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City | WEEKI WACHEE
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State | FL
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Zip | 34613-4532
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Country | US
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Telephone | 727-267-0613
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA30231
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License Number State | FL
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