Healthcare Provider Details

I. General information

NPI: 1932649159
Provider Name (Legal Business Name): LARISA ULVIJA LUKOSS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 E BELL RD STE 205
SCOTTSDALE AZ
85254-6002
US

IV. Provider business mailing address

PO BOX 1200
PLEASANT GROVE UT
84062-1200
US

V. Phone/Fax

Practice location:
  • Phone: 800-640-3451
  • Fax:
Mailing address:
  • Phone: 800-640-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP017306
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP017306
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberSP017306
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number250875
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: