Provider Demographics
NPI:1871195024
Name:GALLAWAY, LARISSA MICHELLE (NNP-BC)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:MICHELLE
Last Name:GALLAWAY
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GOLDMONT ST
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-2790
Mailing Address - Country:US
Mailing Address - Phone:828-606-6804
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-681-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013701363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal