Provider Demographics
NPI:1669497830
Name:LARSON, TRICIA LEE (RN)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:LEE
Other - Last Name:MANTHEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:715 PYLE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4456
Mailing Address - Country:US
Mailing Address - Phone:906-774-0522
Mailing Address - Fax:906-774-1570
Practice Address - Street 1:703 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-1451
Practice Address - Country:US
Practice Address - Phone:906-265-5126
Practice Address - Fax:906-265-5878
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222537163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse