MEDICARE: TKA LLARISSA JOY FOSTER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	11014241	FL

General Provider Information

NPI Number	:	1194398107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TKA LLARISSA JOY FOSTER APRN

Provider Business Mailing Address
First Line	:	3429 NW 44TH ST APT 104
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33309-4270
Country	:	US
Telephone Number	:	754-245-3120
Fax Number	:

Provider Business Practice Location Address
First Line	:	3429 NW 44TH ST APT 104
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33309-4270
Country	:	US
Telephone Number	:	754-245-3120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2021
Last Update Date	:	07/19/2021

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