Provider Demographics
NPI:1053126771
Name:DERUN, LARISA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:DERUN
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 1:14515 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:NE
Mailing Address - Zip Code:68428-4310
Mailing Address - Country:US
Mailing Address - Phone:402-890-2434
Mailing Address - Fax:
Practice Address - Street 1:14515 N 14TH ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:NE
Practice Address - Zip Code:68428-4310
Practice Address - Country:US
Practice Address - Phone:402-890-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant