Individual
LARA KATHLEEN DIVINS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
111 BRIDGE ST, TIONESTA, PA 16353-9737
(814) 755-3631
(814) 755-3633
Mailing address
406 W OAK ST, TITUSVILLE, PA 16354-1404
(814) 755-3631
(814) 755-3633
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
05/02/2012
Last updated
05/31/2021
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