Provider Demographics
NPI:1033797790
Name:LARSEN, ANN (MS (NUTRTION), LMT)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MS (NUTRTION), LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2957
Mailing Address - Country:US
Mailing Address - Phone:517-575-7836
Mailing Address - Fax:
Practice Address - Street 1:1647 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2957
Practice Address - Country:US
Practice Address - Phone:517-575-7836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009069225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty