Provider Demographics
NPI:1427098094
Name:LARIVIERE, MARISA LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
Last Name:LARIVIERE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN-CANFIELD ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-7010
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3658
Practice Address - Fax:330-480-3439
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN229276367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH430066463OtherMEDICARE RAILROAD
OH2274088Medicaid
OHLA8229391Medicare ID - Type Unspecified