Provider Demographics
NPI:1699939215
Name:TAYLOR, LARISSA MARA (DC)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MARA
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DC
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 370
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-0370
Mailing Address - Country:US
Mailing Address - Phone:603-447-1131
Mailing Address - Fax:
Practice Address - Street 1:14 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6042
Practice Address - Country:US
Practice Address - Phone:603-447-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-13
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH797-0807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor