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General NPI Number Information
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NPI Number | 1174200851
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Entity Type | Individual
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Provider Name | LARISSA RENEE BANNON
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Gender | Female
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Dates
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Enumeration Date | 07/03/2023
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 1575 POND RD STE 203
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City | ALLENTOWN
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State | PA
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Zip | 18104-2254
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Country | US
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Telephone | 610-366-1366
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 MACK BLVD FL 4
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City | ALLENTOWN
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State | PA
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Zip | 18103-5622
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Country | US
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Telephone | 484-884-4500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 2109
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | AT007075
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License Number State | PA
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