=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306636352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISSA SUTPHEN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 MOUNTAIN CT
-----------------------------------------------------
City | HACKETTSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07840-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-727-3241
-----------------------------------------------------
Fax | 201-727-3241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 MOUNTAIN CT
-----------------------------------------------------
City | HACKETTSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07840-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-727-3241
-----------------------------------------------------
Fax | 201-727-3241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP.AP.70018897-NP
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 10032542
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ15355300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | SP033108
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 407392
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------