Provider Demographics
NPI:1851465694
Name:LARSON, KIMBERLY RAE (MS, RD, LN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RAE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N 19TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3920
Mailing Address - Country:US
Mailing Address - Phone:406-522-4601
Mailing Address - Fax:406-522-4656
Practice Address - Street 1:120 N 19TH AVE STE D
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3920
Practice Address - Country:US
Practice Address - Phone:406-522-4601
Practice Address - Fax:406-522-4656
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT500133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT500OtherLICENSED NUTRITIONIST