Healthcare Provider Details

I. General information

NPI: 1821479908
Provider Name (Legal Business Name): LARISSA DIANE WATSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 DECATUR BLVD
INDIANAPOLIS IN
46241-9579
US

IV. Provider business mailing address

5940 DECATUR BLVD
INDIANAPOLIS IN
46241-9579
US

V. Phone/Fax

Practice location:
  • Phone: 317-856-2945
  • Fax: 317-856-5122
Mailing address:
  • Phone: 317-856-2945
  • Fax: 317-856-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71005553A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023916
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209023916
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28208703A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71005553A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: