Provider Demographics
NPI:1710530332
Name:GREENWELL, LARISSE DUARTE
Entity Type:Individual
Prefix:MRS
First Name:LARISSE
Middle Name:DUARTE
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 S RED RD STE 229
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5408
Mailing Address - Country:US
Mailing Address - Phone:305-448-9018
Mailing Address - Fax:
Practice Address - Street 1:5000 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2008
Practice Address - Country:US
Practice Address - Phone:305-448-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9325649163W00000X
FL11003552367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse