Provider Demographics
NPI:1114533445
Name:LARSON, BARISSA (RD)
Entity Type:Individual
Prefix:
First Name:BARISSA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12192 HOOSIER RD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9419
Mailing Address - Country:US
Mailing Address - Phone:317-378-6537
Mailing Address - Fax:
Practice Address - Street 1:12192 HOOSIER RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9419
Practice Address - Country:US
Practice Address - Phone:317-378-6537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered