Provider Demographics
NPI:1902235864
Name:CONNELL, LARISSA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:2376 CYPRESS CIRCLE
Practice Address - Street 2:STE 102
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8964
Practice Address - Country:US
Practice Address - Phone:843-347-8953
Practice Address - Fax:843-347-0226
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP8763Medicaid