Provider Demographics
NPI:1629428172
Name:LARSON, TONI
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 25TH AVE S STE 213
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5202
Mailing Address - Country:US
Mailing Address - Phone:701-235-2271
Mailing Address - Fax:701-325-2338
Practice Address - Street 1:1336 25TH AVE S STE 213
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5202
Practice Address - Country:US
Practice Address - Phone:701-235-2271
Practice Address - Fax:701-325-2338
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND410909003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant