Provider Demographics
NPI:1174881775
Name:DIVINS, LARA KATHLEEN
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:KATHLEEN
Last Name:DIVINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:KATHLEEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:406 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1404
Mailing Address - Country:US
Mailing Address - Phone:814-755-3631
Mailing Address - Fax:814-755-3633
Practice Address - Street 1:111 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:TIONESTA
Practice Address - State:PA
Practice Address - Zip Code:16353-9737
Practice Address - Country:US
Practice Address - Phone:814-755-3631
Practice Address - Fax:814-755-3633
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer