Provider Demographics
NPI:1194455204
Name:KOVALEVA, LARISA V (NP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:V
Last Name:KOVALEVA
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 1:13601 RIVERWAY DR APT B
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2678
Mailing Address - Country:US
Mailing Address - Phone:314-238-6730
Mailing Address - Fax:
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-257-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021016885363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care