Provider Demographics
NPI:1164634960
Name:LARSON, KATHY A (LRD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TRINITY HOSPITALS
Mailing Address - Street 2:1 W BURDICK EXPY.
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701
Mailing Address - Country:US
Mailing Address - Phone:701-857-5000
Mailing Address - Fax:701-857-5646
Practice Address - Street 1:TRINITY HOSPITALS
Practice Address - Street 2:1 W BURDICK EXPY.
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701
Practice Address - Country:US
Practice Address - Phone:701-857-5000
Practice Address - Fax:701-857-5646
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered