Provider Demographics
NPI:1679857932
Name:KING, LARA N (FNP)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:N
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 29TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-2675
Mailing Address - Country:US
Mailing Address - Phone:601-286-5477
Mailing Address - Fax:601-286-5825
Practice Address - Street 1:4803 29TH AVE STE A
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2675
Practice Address - Country:US
Practice Address - Phone:601-286-5477
Practice Address - Fax:601-286-5825
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856339363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01384559Medicaid