Provider Demographics
NPI:1710139415
Name:LARAISO, PHYLLIS (CNM)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:LARAISO
Suffix:
Gender:F
Credentials:CNM
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 408
Mailing Address - Street 2:
Mailing Address - City:KAUNAKAKAI
Mailing Address - State:HI
Mailing Address - Zip Code:96748-0408
Mailing Address - Country:US
Mailing Address - Phone:808-553-3145
Mailing Address - Fax:808-553-3163
Practice Address - Street 1:280 HOME OLU PLACE
Practice Address - Street 2:
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748
Practice Address - Country:US
Practice Address - Phone:808-553-3145
Practice Address - Fax:808-553-3163
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-140367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife