Provider Demographics
NPI:1760916811
Name:KONONOV, LARISA (ADMINISTRATOR)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:KONONOV
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 WINONA WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-5636
Mailing Address - Country:US
Mailing Address - Phone:916-628-9097
Mailing Address - Fax:916-568-9752
Practice Address - Street 1:3620 WINONA WAY
Practice Address - Street 2:
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660-5636
Practice Address - Country:US
Practice Address - Phone:916-628-9097
Practice Address - Fax:916-568-9752
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-16
Last Update Date:2017-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347003494171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor