Provider Demographics
NPI:1114639986
Name:POGORELOVA, LARISA
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:POGORELOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:
Other - Last Name:MYAKHKOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24828 TODDY LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704320981163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704320981OtherMICHIGAN BOARD OF NURSING