Provider Demographics
NPI:1477229573
Name:LARSON, KELSEY NOEL (PMHNP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:NOEL
Last Name:LARSON
Suffix:
Gender:F
Credentials:PMHNP
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 4TH ST S STE 500
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1939
Practice Address - Country:US
Practice Address - Phone:701-234-4141
Practice Address - Fax:701-234-4137
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR39988363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health