Provider Demographics
NPI:1710232236
Name:LARSON, TIANA J (CNM)
Entity Type:Individual
Prefix:MS
First Name:TIANA
Middle Name:J
Last Name:LARSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 WATER ST
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614-5231
Mailing Address - Country:US
Mailing Address - Phone:207-374-3940
Mailing Address - Fax:207-374-3980
Practice Address - Street 1:57 WATER ST
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614-5231
Practice Address - Country:US
Practice Address - Phone:207-374-3940
Practice Address - Fax:207-374-3980
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001490176B00000X
WAAP60401092367A00000X
MECNM142001176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife