Basic Information
| Provider Information | |||||||||
| NPI: | 1467868133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDMONDS | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20805 W 151ST ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660617249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137804900 | ||||||||
| FaxNumber: | 9137800949 | ||||||||
| Practice Location | |||||||||
| Address1: | 20805 W 151ST ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660617249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137804900 | ||||||||
| FaxNumber: | 9137800949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2014 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53-76087-022 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201097910A | 05 | KS | MEDICAID |