MEDICARE: LARISSA JEROMINOW

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	363L00000X	Nurse Practitioner	F30911-01	NY
2	363LG0600X	Gerontology Nurse Practitioner	F309311-01	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1205559812	OTHER		NURSE PRACTITIONER-ADULT GERONTOLOGY

General Provider Information

NPI Number	:	1285284992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA JEROMINOW

Provider Business Mailing Address
First Line	:	926 MAIN ST
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-3614
Country	:	US
Telephone Number	:	615-436-9060
Fax Number	:	615-235-9725

Provider Business Practice Location Address
First Line	:	3611 14TH AVE STE 550
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-3773
Country	:	US
Telephone Number	:	718-819-6144
Fax Number	:	718-819-6145

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

Provider Enumeration Date	:	09/14/2019
Last Update Date	:	07/29/2025

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Directions to “ LARISSA JEROMINOW ” Practice Location

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