Provider Demographics
NPI:1225663834
Name:LARSON, LAURESA (RDN)
Entity Type:Individual
Prefix:
First Name:LAURESA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 S 54TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8125
Mailing Address - Country:US
Mailing Address - Phone:479-308-8242
Mailing Address - Fax:
Practice Address - Street 1:2108 S 54TH ST STE 3
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8125
Practice Address - Country:US
Practice Address - Phone:479-308-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1746133V00000X
86007505133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered