Provider Demographics
NPI:1609751338
Name:VANCE, LARA MICHAELA (PTA)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:MICHAELA
Last Name:VANCE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8435 PANAHAN DR
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-4532
Mailing Address - Country:US
Mailing Address - Phone:727-267-0613
Mailing Address - Fax:
Practice Address - Street 1:21760 FL-54 #102
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549
Practice Address - Country:US
Practice Address - Phone:813-252-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30231225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant