Provider Demographics
NPI:1346000270
Name:LARSEN, BROOKE MCKELL
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MCKELL
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 912042
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791-2042
Mailing Address - Country:US
Mailing Address - Phone:435-215-0228
Mailing Address - Fax:
Practice Address - Street 1:2891 E MALL DR STE 101
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2399
Practice Address - Country:US
Practice Address - Phone:435-656-2424
Practice Address - Fax:435-656-2828
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT651705-4405363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology