Provider Demographics
NPI:1548021173
Name:GORRIS, LARISA MARY ANN (RDN)
Entity type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:MARY ANN
Last Name:GORRIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7063 ELPHICK RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4701
Mailing Address - Country:US
Mailing Address - Phone:530-210-3618
Mailing Address - Fax:
Practice Address - Street 1:1443 MAIN ST STE 130B
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-1939
Practice Address - Country:US
Practice Address - Phone:707-200-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86131553133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered