Provider Demographics
NPI:1760030050
Name:FRAUENHEIM, LARISSA KATHLEEN (APRN)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:KATHLEEN
Last Name:FRAUENHEIM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:KATHLEEN
Other - Last Name:BRETTELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2036 SEA HAWK CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1785
Practice Address - Country:US
Practice Address - Phone:229-443-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN287176363LF0000X
FLRN9336400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily