Provider Demographics
NPI:1245670769
Name:SHIMONOV, LARISA (RN)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:SHIMONOV
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 1:11622 METROPOLITAN AVE # 3
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1017
Mailing Address - Country:US
Mailing Address - Phone:718-916-0942
Mailing Address - Fax:
Practice Address - Street 1:11622 METROPOLITAN AVE # 3
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1017
Practice Address - Country:US
Practice Address - Phone:718-916-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY583006163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse