Provider Demographics
NPI:1013389733
Name:LARSON, CORINNE S (RDN, CDN)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:S
Last Name:LARSON
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DARLING ST
Mailing Address - Street 2:APT C
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2616
Mailing Address - Country:US
Mailing Address - Phone:203-915-6079
Mailing Address - Fax:
Practice Address - Street 1:50 GAYLORD FARM RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2828
Practice Address - Country:US
Practice Address - Phone:203-741-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1376133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered