Provider Demographics
NPI:1508013392
Name:LARSON, COLLEEN M (BSN, RN)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:OLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2624 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2350
Mailing Address - Country:US
Mailing Address - Phone:701-298-4500
Mailing Address - Fax:701-298-4400
Practice Address - Street 1:2624 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2350
Practice Address - Country:US
Practice Address - Phone:701-298-4500
Practice Address - Fax:701-298-4400
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR18305163W00000X
MNR88901-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse