Provider Demographics
NPI:1619964244
Name:LARSEN, DIANA LORRAINE (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LORRAINE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:NP
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 1285
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-1285
Mailing Address - Country:US
Mailing Address - Phone:530-458-5565
Mailing Address - Fax:530-458-2838
Practice Address - Street 1:348 MARKET ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2422
Practice Address - Country:US
Practice Address - Phone:530-458-5565
Practice Address - Fax:530-458-2838
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP545628163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN545628Medicaid
CAP53516Medicare UPIN
CARN545628Medicaid