Provider Demographics
NPI:1417331083
Name:LARSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LARSON
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 1:9025 POMELO RD W
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3723
Mailing Address - Country:US
Mailing Address - Phone:239-265-3391
Mailing Address - Fax:
Practice Address - Street 1:9025 POMELO RD W
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-3723
Practice Address - Country:US
Practice Address - Phone:239-265-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9227059363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology