Provider Demographics
NPI:1710316302
Name:LARSON, MELISSA KAY (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:KAY
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:BERKEY
Mailing Address - State:OH
Mailing Address - Zip Code:43504-9660
Mailing Address - Country:US
Mailing Address - Phone:517-605-8014
Mailing Address - Fax:
Practice Address - Street 1:1325 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2526
Practice Address - Country:US
Practice Address - Phone:517-605-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704247109163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse