Provider Demographics
NPI:1154818755
Name:LARSON, REGINA MARIE (RD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 122ND AVE E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-2420
Mailing Address - Country:US
Mailing Address - Phone:253-948-7644
Mailing Address - Fax:
Practice Address - Street 1:3415 122ND AVE E
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98372-2420
Practice Address - Country:US
Practice Address - Phone:253-948-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered