Provider Demographics
NPI:1992565642
Name:DEPASQUA, LARISSA (RDN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:DEPASQUA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 MOSAIC BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3777
Mailing Address - Country:US
Mailing Address - Phone:386-315-4222
Mailing Address - Fax:
Practice Address - Street 1:769 BROADWAY # 1019
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6803
Practice Address - Country:US
Practice Address - Phone:386-315-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12218133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered