Provider Demographics
NPI:1023607017
Name:OBERHOLTZER-GALLAGHER, LARISSA MICHELE (RN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MICHELE
Last Name:OBERHOLTZER-GALLAGHER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:CA
Mailing Address - Zip Code:94517-1715
Mailing Address - Country:US
Mailing Address - Phone:925-693-0545
Mailing Address - Fax:
Practice Address - Street 1:2 REGENCY DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:CA
Practice Address - Zip Code:94517-1715
Practice Address - Country:US
Practice Address - Phone:925-693-0545
Practice Address - Fax:925-693-0545
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA562922163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
888OtherNOT APPLICABLE