=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396283933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARISA BIZNICHUK MSN PMHNP-BC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2017
-----------------------------------------------------
Last Update Date | 02/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 N ORACLE RD STE 121
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-638-5997
-----------------------------------------------------
Fax | 520-638-6948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 N ORACLE RD STE 121
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-638-5997
-----------------------------------------------------
Fax | 520-638-6948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LARISA D BISNICHUK
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 520-638-5997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP3414
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------