Provider Demographics
NPI:1265650287
Name:LARSON, MELANIE DAWN (LVN MHT II)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:DAWN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LVN MHT II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 S MOONEY BLVD
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-9394
Mailing Address - Country:US
Mailing Address - Phone:559-623-1178
Mailing Address - Fax:
Practice Address - Street 1:520 E TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292-3629
Practice Address - Country:US
Practice Address - Phone:559-623-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAVN 191781164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator