Provider Demographics
NPI:1578997227
Name:LARSON, NANCY JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:JEAN
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19450 BLACK RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95033-9598
Mailing Address - Country:US
Mailing Address - Phone:408-354-3525
Mailing Address - Fax:
Practice Address - Street 1:19450 BLACK RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95033-9598
Practice Address - Country:US
Practice Address - Phone:408-354-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA578844163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3Medicaid
CA3Medicaid