Provider Demographics
NPI:1043663917
Name:LARRISON, JOHN (APN, FNP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LARRISON
Suffix:
Gender:M
Credentials:APN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CHICK ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2467
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-524-4131
Practice Address - Street 1:28 CHICK ST STE 100
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-2176
Practice Address - Fax:618-524-4131
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily