Provider Demographics
NPI:1811642994
Name:HACKETT, LARISSA BRIAUN
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:BRIAUN
Last Name:HACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S G ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1817
Mailing Address - Country:US
Mailing Address - Phone:541-947-6021
Mailing Address - Fax:541-219-8114
Practice Address - Street 1:87520 BAY RD
Practice Address - Street 2:
Practice Address - City:CHRISTMAS VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97641-2233
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:541-576-3000
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program