Healthcare Provider Details

I. General information

NPI: 1699314971
Provider Name (Legal Business Name): LARISA KING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 ADAMS FARM PKWY
GREENSBORO NC
27407-6338
US

IV. Provider business mailing address

713 S MARSHALL ST
WINSTON SALEM NC
27101-5808
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-7266
  • Fax: 336-201-0538
Mailing address:
  • Phone: 336-722-7266
  • Fax: 336-201-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5012717
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178286
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: