1649192212 NPI number — MRS. LARISSA PEARL PRESTADO CLAVILLAS APRN

Table of content: MRS. LARISSA PEARL PRESTADO CLAVILLAS APRN (NPI 1649192212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649192212 NPI number — MRS. LARISSA PEARL PRESTADO CLAVILLAS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAVILLAS
Provider First Name:
LARISSA PEARL
Provider Middle Name:
PRESTADO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRESTADO
Provider Other First Name:
LARISSA PEARL
Provider Other Middle Name:
DIMAIWAT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649192212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 26TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODWARD
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73801-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-254-8192
Provider Business Mailing Address Fax Number:
580-254-8687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODWARD
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73801-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-254-8192
Provider Business Practice Location Address Fax Number:
580-254-8687
Provider Enumeration Date:
07/27/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  228654 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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