Provider Demographics
NPI:1285284992
Name:JEROMINOW, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:JEROMINOW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-3614
Mailing Address - Country:US
Mailing Address - Phone:615-436-9060
Mailing Address - Fax:615-235-9725
Practice Address - Street 1:65 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3718
Practice Address - Country:US
Practice Address - Phone:718-819-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF30911-01363L00000X
NYF309311-01363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
1205559812OtherNURSE PRACTITIONER-ADULT GERONTOLOGY