Healthcare Provider Details

I. General information

NPI: 1306636352
Provider Name (Legal Business Name): LARISSA SUTPHEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MOUNTAIN CT
HACKETTSTOWN NJ
07840-2317
US

IV. Provider business mailing address

119 MOUNTAIN CT
HACKETTSTOWN NJ
07840-2317
US

V. Phone/Fax

Practice location:
  • Phone: 201-727-3241
  • Fax: 201-727-3241
Mailing address:
  • Phone: 201-727-3241
  • Fax: 201-727-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP.AP.70018897-NP
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10032542
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15355300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP033108
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407392
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: