Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC5404 | TX |
NPI | 1417012139 |
---|---|
Provider Name | Ms. Cynthia Lorena Lara |
First Address | Austin, TX 78731-4975 |
Second Address | Austin, TX 78731-4975 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2006 |
Last Update Date | 08/07/2007 |