Provider Demographics
NPI:1013478569
Name:LARIE, SHAYE (NP)
Entity Type:Individual
Prefix:
First Name:SHAYE
Middle Name:
Last Name:LARIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1074
Mailing Address - Street 2:
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-1074
Mailing Address - Country:US
Mailing Address - Phone:208-954-3525
Mailing Address - Fax:
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60704363LF0000X
CA95207424363LP2300X
CANP95207424363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily