Provider Demographics
NPI:1912604539
Name:DYAKOVA, LARISA ANATOLYEVNA (FNP)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:ANATOLYEVNA
Last Name:DYAKOVA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4361
Mailing Address - Country:US
Mailing Address - Phone:740-655-2631
Mailing Address - Fax:
Practice Address - Street 1:702 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1199
Practice Address - Country:US
Practice Address - Phone:575-748-3333
Practice Address - Fax:575-736-8139
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0032705363LF0000X
NM79627363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily