Healthcare Provider Details

I. General information

NPI: 1053191163
Provider Name (Legal Business Name): LARISSA ROSE O'KEEFE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CORPORATE LAKE DR
COLUMBIA MO
65203-7172
US

IV. Provider business mailing address

4823 LOYALIST LN
ASHLAND MO
65010-9418
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-1170
  • Fax:
Mailing address:
  • Phone: 573-301-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2023040439
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: