Provider Demographics
NPI:1861940694
Name:DAVYDOVA, LARISA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:DAVYDOVA
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 1:1329 SW 16TH ST RM 2232
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1128
Mailing Address - Country:US
Mailing Address - Phone:352-733-0485
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:718-354-9846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6740367500000X
FLAPRN11000691367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered