Provider Demographics
NPI:1447524863
Name:WILLIAMS, LARISSA LYNNE
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:LYNNE
Last Name:WILLIAMS
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 1:9 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:ME
Mailing Address - Zip Code:04929-3213
Mailing Address - Country:US
Mailing Address - Phone:207-341-5541
Mailing Address - Fax:
Practice Address - Street 1:9 RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:ME
Practice Address - Zip Code:04929-3213
Practice Address - Country:US
Practice Address - Phone:207-341-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula