Provider Demographics
NPI:1679766224
Name:IENNA, LARISSA CHRISTINE (FNP)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:CHRISTINE
Last Name:IENNA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 NW 22ND AVE #520
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-413-7557
Mailing Address - Fax:
Practice Address - Street 1:500 N COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1299
Practice Address - Country:US
Practice Address - Phone:503-397-0471
Practice Address - Fax:503-366-5519
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200340678163W00000X
OR200850116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse