Provider Demographics
NPI:1306636352
Name:SUTPHEN, LARISSA (APRN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:SUTPHEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18766-0997
Mailing Address - Country:US
Mailing Address - Phone:908-235-6636
Mailing Address - Fax:
Practice Address - Street 1:84 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18766-1041
Practice Address - Country:US
Practice Address - Phone:908-235-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP033108363LP0808X
NJ26NR18529100163W00000X
OR10032542163W00000X
NV859561163W00000X
NY860352163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health