Provider Demographics
NPI:1619133832
Name:LARSON, MARY F (LRD, MPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:F
Last Name:LARSON
Suffix:
Gender:F
Credentials:LRD, MPH
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 2625
Mailing Address - Street 2:FAMILY HEALTHCARE CENTER
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-2625
Mailing Address - Country:US
Mailing Address - Phone:701-271-3344
Mailing Address - Fax:701-271-3343
Practice Address - Street 1:306 4TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4820
Practice Address - Country:US
Practice Address - Phone:701-271-3344
Practice Address - Fax:701-271-3343
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND435133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered