Provider Demographics
NPI:1396030862
Name:LARSEN, CHANNA
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:
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 1:3362 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-1512
Mailing Address - Country:US
Mailing Address - Phone:402-564-1124
Mailing Address - Fax:402-563-0710
Practice Address - Street 1:3362 53RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1512
Practice Address - Country:US
Practice Address - Phone:402-564-1124
Practice Address - Fax:402-563-0710
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48472163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse