MEDICARE: LARA JOY SULTAN FNTP, CPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	3305	WA

General Provider Information

NPI Number	:	1124758750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA JOY SULTAN FNTP, CPT

Provider Business Mailing Address
First Line	:	PO BOX 8626
Second Line	:
City	:	HOT SPRINGS VILLAGE
State	:	AR
Zip	:	71910-8626
Country	:	US
Telephone Number	:	760-518-9431
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 SPUR RANCH AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8108
Country	:	US
Telephone Number	:	760-518-9431
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	06/15/2022

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