Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 60704 | ID |
N | 363LP2300X | Nurse Practitioner - Primary Care | 95207424 | CA |
NPI | 1013478569 |
---|---|
Provider Name | Shaye Larie |
First Address | Santa Rosa, CA 95401-4122 |
Second Address | Santa Rosa, CA 95401-4122 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2019 |
Last Update Date | 25/10/2019 |