Provider Demographics
NPI:1831412303
Name:ROGERS, LARISSA JOAN (RN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:JOAN
Last Name:ROGERS
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 1:1725 N GEORGE MASON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3675
Mailing Address - Country:US
Mailing Address - Phone:703-228-4996
Mailing Address - Fax:703-228-5157
Practice Address - Street 1:1725 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3675
Practice Address - Country:US
Practice Address - Phone:703-228-4996
Practice Address - Fax:703-228-5157
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001151480163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse