Provider Demographics
NPI:1609475425
Name:VENHAUS, LARISSA DIMELO (WHNP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:DIMELO
Last Name:VENHAUS
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 DAVE KAY ST
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3613
Mailing Address - Country:US
Mailing Address - Phone:618-207-9986
Mailing Address - Fax:
Practice Address - Street 1:4251 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:314-531-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020026044363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health