Provider Demographics
NPI:1073112934
Name:LARSON, DIANE KAY II
Entity Type:Individual
Prefix:PROF
First Name:DIANE
Middle Name:KAY
Last Name:LARSON
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:ND
Mailing Address - Zip Code:58488-8809
Mailing Address - Country:US
Mailing Address - Phone:701-867-2535
Mailing Address - Fax:
Practice Address - Street 1:100 N ANDERSON ST
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:ND
Practice Address - Zip Code:58488-8809
Practice Address - Country:US
Practice Address - Phone:701-867-2535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child