Provider Demographics
NPI:1740051945
Name:LARSEN, MARISA JOAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:JOAN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BEACH 135TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1305
Mailing Address - Country:US
Mailing Address - Phone:347-782-3632
Mailing Address - Fax:
Practice Address - Street 1:219 BEACH 135TH ST
Practice Address - Street 2:
Practice Address - City:BELLE HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11694-1305
Practice Address - Country:US
Practice Address - Phone:347-782-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily