Provider Demographics
NPI:1558646570
Name:LARSON, ZOEY L (CNA)
Entity Type:Individual
Prefix:
First Name:ZOEY
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 S BAKER RD
Mailing Address - Street 2:
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810-2118
Mailing Address - Country:US
Mailing Address - Phone:715-410-7990
Mailing Address - Fax:
Practice Address - Street 1:1989 S BAKER RD
Practice Address - Street 2:
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-2118
Practice Address - Country:US
Practice Address - Phone:715-410-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI270670374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide