Provider Demographics
NPI:1063832731
Name:DAVIS, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WARD ST EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:STE 201
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2201
Practice Address - Country:US
Practice Address - Phone:912-384-9460
Practice Address - Fax:912-393-1239
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN197160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145835AMedicaid
GARN197160OtherMEDICAL LICENSE