Provider Demographics
NPI:1619379724
Name:MELISSA DEE LARSEN
Entity Type:Organization
Organization Name:MELISSA DEE LARSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:515-250-4194
Mailing Address - Street 1:2423 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-1721
Mailing Address - Country:US
Mailing Address - Phone:515-250-4194
Mailing Address - Fax:
Practice Address - Street 1:5005 DOUGLAS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2760
Practice Address - Country:US
Practice Address - Phone:515-724-8920
Practice Address - Fax:888-771-3225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG087693261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)