Provider Demographics
NPI:1588543334
Name:MAHONEY, LARISSA KAREN (RD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:KAREN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 WENTZ CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5715
Mailing Address - Country:US
Mailing Address - Phone:215-571-5723
Mailing Address - Fax:
Practice Address - Street 1:2007 WENTZ CHURCH RD
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5715
Practice Address - Country:US
Practice Address - Phone:215-571-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007433133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered