Provider Demographics
NPI:1154836575
Name:DAVIS, LARISSA CHRISTINE
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:CHRISTINE
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 1:2967 WINTERS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1228
Mailing Address - Country:US
Mailing Address - Phone:304-923-4620
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN MARSHALL DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25755-0002
Practice Address - Country:US
Practice Address - Phone:304-923-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer