Provider Demographics
NPI:1932839198
Name:DE LEON, LARISSA ANNE
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANNE
Last Name:DE LEON
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 1:400 10TH ST NW APT 226
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-2258
Mailing Address - Country:US
Mailing Address - Phone:956-648-5278
Mailing Address - Fax:
Practice Address - Street 1:400 10TH ST NW APT 226
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2258
Practice Address - Country:US
Practice Address - Phone:956-648-5278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX820926163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse