Provider Demographics
NPI:1629555321
Name:LARGER, LONNA LOUISE (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LONNA
Middle Name:LOUISE
Last Name:LARGER
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 LICKING PIKE
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2912
Mailing Address - Country:US
Mailing Address - Phone:859-572-0400
Mailing Address - Fax:859-442-3363
Practice Address - Street 1:519 LICKING PIKE
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41071-2912
Practice Address - Country:US
Practice Address - Phone:859-572-0400
Practice Address - Fax:859-442-3363
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-0024120363LP0808X
OH023330363LP0808X
KY4011274363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100919790Medicaid
OH0321608Medicaid