Provider Demographics
NPI:1851893069
Name:RICH, LARISSA MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MICHELLE
Last Name:RICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4537 HENSLEY DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-8153
Mailing Address - Country:US
Mailing Address - Phone:931-397-2593
Mailing Address - Fax:
Practice Address - Street 1:5000 CROSSINGS CIR STE 101
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8591
Practice Address - Country:US
Practice Address - Phone:615-553-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant