Provider Demographics
NPI:1548017114
Name:LARA PETRICK, MONTSERRAT ANILU (SA-C)
Entity type:Individual
Prefix:
First Name:MONTSERRAT
Middle Name:ANILU
Last Name:LARA PETRICK
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 COURSE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7274
Mailing Address - Country:US
Mailing Address - Phone:904-651-6742
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-861-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24-239246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant