Provider Demographics
NPI:1073295655
Name:LARREABETZ, SOFIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:ELIZABETH
Last Name:LARREABETZ
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 1:15005 W CROCUS DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-6044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11441 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-3402
Practice Address - Country:US
Practice Address - Phone:623-412-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ278643164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse