Provider Demographics
NPI:1467868133
Name:EDMONDS, LARISSA R
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:R
Last Name:EDMONDS
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 1:20805 W 151ST ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7249
Mailing Address - Country:US
Mailing Address - Phone:913-780-4900
Mailing Address - Fax:913-780-0949
Practice Address - Street 1:20805 W 151ST ST
Practice Address - Street 2:SUITE 400
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7249
Practice Address - Country:US
Practice Address - Phone:913-780-4900
Practice Address - Fax:913-780-0949
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76087-022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201097910AMedicaid
KS201097910AMedicaid