Provider Demographics
NPI:1124668751
Name:TREGILLIES, LARA M (NP)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:TREGILLIES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2241
Mailing Address - Country:US
Mailing Address - Phone:718-980-1553
Mailing Address - Fax:
Practice Address - Street 1:130 ROSE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2241
Practice Address - Country:US
Practice Address - Phone:718-980-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty