Provider Demographics
NPI:1093455388
Name:THURSTON, KUYANN LARISSA (NP)
Entity Type:Individual
Prefix:
First Name:KUYANN
Middle Name:LARISSA
Last Name:THURSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 LANKERSHIM BLVD APT 334
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3435
Mailing Address - Country:US
Mailing Address - Phone:678-600-5951
Mailing Address - Fax:
Practice Address - Street 1:6201 HOLLYWOOD BLVD UNIT 1510
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-5373
Practice Address - Country:US
Practice Address - Phone:678-600-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020545363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner