Healthcare Provider Details

I. General information

NPI: 1144678905
Provider Name (Legal Business Name): LARINA BRANCH DNP-FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST STE 3H
HAZEL CREST IL
60429-2186
US

IV. Provider business mailing address

18300 S. HALSTED ST SUITE B #255
GLENWOOD IL
60425
US

V. Phone/Fax

Practice location:
  • Phone: 708-816-4418
  • Fax: 949-818-7145
Mailing address:
  • Phone: 708-816-4418
  • Fax: 949-818-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number277002770
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277002770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: