Healthcare Provider Details

I. General information

NPI: 1457095465
Provider Name (Legal Business Name): LARISSA FON TENDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 EASTVIEW CT
BOWIE MD
20716-7328
US

IV. Provider business mailing address

4011 EASTVIEW CT
BOWIE MD
20716-7328
US

V. Phone/Fax

Practice location:
  • Phone: 240-381-7778
  • Fax:
Mailing address:
  • Phone: 240-381-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: