Provider Demographics
NPI:1598766768
Name:BAILEY, LARISSA L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:L
Last Name:BAILEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:EAST BERNSTADT
Mailing Address - State:KY
Mailing Address - Zip Code:40729
Mailing Address - Country:US
Mailing Address - Phone:606-843-2339
Mailing Address - Fax:606-843-6815
Practice Address - Street 1:1655 EAST HWY 3094
Practice Address - Street 2:
Practice Address - City:EAST BERNSTADT
Practice Address - State:KY
Practice Address - Zip Code:40729
Practice Address - Country:US
Practice Address - Phone:606-843-2339
Practice Address - Fax:606-843-6815
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4075P363L00000X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78010170Medicaid
KY37903705OtherMEDICAID LAB GROUP
KYCB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP
KYP92772Medicare UPIN
KY78010170Medicaid