Provider Demographics
NPI:1316213713
Name:LARSON, KAREN K (LD, MS)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:K
Last Name:LARSON
Suffix:
Gender:F
Credentials:LD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12605 LAKE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-6432
Mailing Address - Country:US
Mailing Address - Phone:813-671-1090
Mailing Address - Fax:
Practice Address - Street 1:12605 LAKE HILLS DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-6432
Practice Address - Country:US
Practice Address - Phone:813-671-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2428133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist