Provider Demographics
NPI:1437455482
Name:LARSON, MICHELE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 N 210 W
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9124
Mailing Address - Country:US
Mailing Address - Phone:435-224-3161
Mailing Address - Fax:
Practice Address - Street 1:1831 N 210 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9124
Practice Address - Country:US
Practice Address - Phone:435-224-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375534-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily