Provider Demographics
NPI:1669567020
Name:WELCH, LARISA M (FNP)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:M
Last Name:WELCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:M
Other - Last Name:LEAST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:2 CHABOT ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092
Mailing Address - Country:US
Mailing Address - Phone:207-857-9311
Mailing Address - Fax:207-857-9324
Practice Address - Street 1:2 CHABOT ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-857-9311
Practice Address - Fax:207-857-9324
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER050944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431956199Medicaid
NP5140Medicare UPIN
Q52699Medicare UPIN
NP5140Medicare ID - Type Unspecified