Provider Demographics
NPI:1053844811
Name:FLORES, LARISSA
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:
Last Name:FLORES
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 1:300 W CLARENDON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3422
Mailing Address - Country:US
Mailing Address - Phone:602-776-0776
Mailing Address - Fax:602-705-0567
Practice Address - Street 1:300 W CLARENDON AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3422
Practice Address - Country:US
Practice Address - Phone:602-776-0776
Practice Address - Fax:602-705-0567
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9917363LP0808X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ201263OtherMEDICARE
AZ257668Medicaid