Provider Demographics
NPI:1720122054
Name:BOTCHARNIKOVA, LARISSA N (NP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:N
Last Name:BOTCHARNIKOVA
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 992790
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-2790
Mailing Address - Country:US
Mailing Address - Phone:530-246-5710
Mailing Address - Fax:530-241-7838
Practice Address - Street 1:1035 PLACER ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1125
Practice Address - Country:US
Practice Address - Phone:530-246-5710
Practice Address - Fax:530-241-7838
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner