Provider Demographics
NPI:1518740182
Name:ROMERO, LARISSA NICOLE
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:NICOLE
Last Name:ROMERO
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 1:3513 W MESA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-1547
Mailing Address - Country:US
Mailing Address - Phone:559-577-2059
Mailing Address - Fax:
Practice Address - Street 1:309 S. GATEWAY DR.
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637
Practice Address - Country:US
Practice Address - Phone:559-674-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist