Provider Demographics
NPI:1104550813
Name:LARA, DANETTE
Entity type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:GORMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76454-0125
Mailing Address - Country:US
Mailing Address - Phone:254-734-5196
Mailing Address - Fax:
Practice Address - Street 1:414 N POTTER ST
Practice Address - Street 2:
Practice Address - City:GORMAN
Practice Address - State:TX
Practice Address - Zip Code:76454-7645
Practice Address - Country:US
Practice Address - Phone:254-734-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
TX406749222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program