Provider Demographics
NPI:1710205331
Name:NALL, LARISSA (PTA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:NALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 MAIN DR
Mailing Address - Street 2:SUITE #5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2403 MAIN DR
Practice Address - Street 2:SUITE #5
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5223
Practice Address - Country:US
Practice Address - Phone:479-966-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1338225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant