Healthcare Provider Details

I. General information

NPI: 1497205173
Provider Name (Legal Business Name): LARISSA GOURDET A.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 GLEN COVE AVE
GLEN HEAD NY
11545-1593
US

IV. Provider business mailing address

997 GLEN COVE AVE
GLEN HEAD NY
11545-1593
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-9144
  • Fax:
Mailing address:
  • Phone: 516-674-9144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307969
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: