Healthcare Provider Details

I. General information

NPI: 1912604539
Provider Name (Legal Business Name): LARISA ANATOLYEVNA DYAKOVA APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 KENNY RD FL 8
COLUMBUS OH
43221-3502
US

IV. Provider business mailing address

2050 KENNY RD FL 8
COLUMBUS OH
43221-3502
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-4272
  • Fax: 614-366-9440
Mailing address:
  • Phone: 614-366-4272
  • Fax: 614-366-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0032705
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0032705
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number79627
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: