Provider Demographics
NPI:1720195167
Name:LARSON, REBECCA ANN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4631
Mailing Address - Country:US
Mailing Address - Phone:906-776-9040
Mailing Address - Fax:906-774-7279
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:906-776-9040
Practice Address - Fax:906-774-7279
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704208185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4446672Medicaid
MIOP383400009Medicare Oscar/Certification
MIP00697652Medicare Oscar/Certification
MI4446672Medicaid