Provider Demographics
NPI:1902237852
Name:MEGOUJOU FOSSO, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:MEGOUJOU FOSSO
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 1:7777 MAPLE AVE APT 1211
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5650
Mailing Address - Country:US
Mailing Address - Phone:202-763-2653
Mailing Address - Fax:
Practice Address - Street 1:7777 MAPLE AVE APT 1211
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-5650
Practice Address - Country:US
Practice Address - Phone:202-763-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM221488018967OtherMULTIPLAN