Basic Information
| Provider Information | |||||||||
| NPI: | 1003189267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARA | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOISWORTHY | ||||||||
| OtherFirstName: | ABBY | ||||||||
| OtherMiddleName: | THOMAS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703263949 | ||||||||
| FaxNumber: | 2703263954 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422404991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707073354 | ||||||||
| FaxNumber: | 2707073351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2012 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007353 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100200240 | 05 | KY | MEDICAID |