Provider Demographics
NPI:1730935743
Name:FAIN, LARISSA ANN
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:ANN
Last Name:FAIN
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:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:OR
Mailing Address - Zip Code:97633-0765
Mailing Address - Country:US
Mailing Address - Phone:541-892-4415
Mailing Address - Fax:
Practice Address - Street 1:1336 AVALON ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4423
Practice Address - Country:US
Practice Address - Phone:541-892-4415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201701461RN163WS0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WS0200XNursing Service ProvidersRegistered NurseSchool