Provider Demographics
NPI:1831723055
Name:LARA, KEANNA (BS)
Entity type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-4016
Mailing Address - Country:US
Mailing Address - Phone:626-423-3194
Mailing Address - Fax:
Practice Address - Street 1:5800 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-4016
Practice Address - Country:US
Practice Address - Phone:626-423-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner