Healthcare Provider Details

I. General information

NPI: 1275854333
Provider Name (Legal Business Name): LARISSA ANN CHISMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7542
US

IV. Provider business mailing address

5301 VIRGINIA WAY STE 300
BRENTWOOD TN
37027-7542
US

V. Phone/Fax

Practice location:
  • Phone: 615-695-4977
  • Fax: 615-263-3348
Mailing address:
  • Phone: 615-695-4977
  • Fax: 615-263-3348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number073928
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: