=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467925909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISSA GBONE NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9711 WASHINGTON BLVD SUITE 550
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-966-2558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3731 SPICEBUSH DR
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21704-7879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-426-3133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R194251
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------