Healthcare Provider Details

I. General information

NPI: 1053729020
Provider Name (Legal Business Name): ELISSA MARIE LARKIN APN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 09/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 S BONNIE BROOK LN
WAUKEGAN IL
60087-3721
US

IV. Provider business mailing address

2311 S BONNIE BROOK LN
WAUKEGAN IL
60087-3721
US

V. Phone/Fax

Practice location:
  • Phone: 831-264-3771
  • Fax: 888-959-0674
Mailing address:
  • Phone: 831-264-3771
  • Fax: 888-959-0674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number148897-32
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209011894
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041421123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: