Provider Demographics
NPI:1093056483
Name:LARSON-BRENDEN, MARY ELIZABETH (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LARSON-BRENDEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MISSOURI VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51555-1718
Mailing Address - Country:US
Mailing Address - Phone:402-680-2546
Mailing Address - Fax:
Practice Address - Street 1:14104 S ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2636
Practice Address - Country:US
Practice Address - Phone:402-614-7385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2017-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA089499363LF0000X
NE111473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily