Provider Demographics
NPI:1508406067
Name:LARSON, KIMBERLY ANNA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNA
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 1:427 31ST ST NW
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-4030
Mailing Address - Country:US
Mailing Address - Phone:406-788-6189
Mailing Address - Fax:
Practice Address - Street 1:1601 2ND AVE N STE 450H
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3259
Practice Address - Country:US
Practice Address - Phone:406-788-6189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist