Provider Demographics
NPI:1174690671
Name:WAEHNER-LARSON, CHRISTINE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:
Last Name:WAEHNER-LARSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1714
Mailing Address - Country:US
Mailing Address - Phone:612-825-6387
Mailing Address - Fax:
Practice Address - Street 1:5770 W BALD EAGLE BLVD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6440
Practice Address - Country:US
Practice Address - Phone:651-429-9595
Practice Address - Fax:651-429-9595
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1075171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP22866OtherHP ID NUMBER