=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700128659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISSA CAMANO-SELCA RN, BSN, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2013
-----------------------------------------------------
Last Update Date | 11/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 EATON CT
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811-4052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-917-9272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1202 EATON CT
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811-4052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-917-9272
-----------------------------------------------------
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 | 005307
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------