Provider Demographics
NPI:1902519713
Name:PETRIE, LARA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:LYNN
Last Name:PETRIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 NW PAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-9685
Mailing Address - Country:US
Mailing Address - Phone:816-510-9312
Mailing Address - Fax:
Practice Address - Street 1:9001 STATE LINE RD STE 300
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3212
Practice Address - Country:US
Practice Address - Phone:816-363-2600
Practice Address - Fax:816-444-1928
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-79706-092163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse