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NPI Code Detail

MEDICARE: LARISSA JEROMINOW

MEDICARE: LARISSA JEROMINOW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse PractitionerF30911-01NY
2363LG0600XGerontology Nurse PractitionerF309311-01NY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11205559812OTHERNURSE PRACTITIONER-ADULT GERONTOLOGY

General Provider Information

NPI Number : 1285284992
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARISSA JEROMINOW
Provider Business Mailing Address
First Line : 926 MAIN ST
Second Line :
City : NASHVILLE
State : TN
Zip : 37206-3614
Country : US
Telephone Number : 615-436-9060
Fax Number : 615-235-9725
Provider Business Practice Location Address
First Line : 3611 14TH AVE STE 550
Second Line :
City : BROOKLYN
State : NY
Zip : 11218-3773
Country : US
Telephone Number : 718-819-6144
Fax Number : 718-819-6145
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/14/2019
Last Update Date : 07/29/2025

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Directions to “ LARISSA JEROMINOW ” Practice Location

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