Provider Demographics
NPI:1003323304
Name:LARSON, KAYLENE NICHOLE (APRN, CRNA)
Entity Type:Individual
Prefix:MS
First Name:KAYLENE
Middle Name:NICHOLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:APRN, CRNA
Other - Prefix:MRS
Other - First Name:KAYLENE
Other - Middle Name:NICHOLE
Other - Last Name:WENDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4161 18TH AVE S APT 117
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7416
Mailing Address - Country:US
Mailing Address - Phone:701-212-2396
Mailing Address - Fax:
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3302
Practice Address - Country:US
Practice Address - Phone:320-235-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered