Provider Demographics
NPI:1922328483
Name:LARSON, PAMELA KAY (LPN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:KAY
Last Name:LARSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 121
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472
Mailing Address - Country:US
Mailing Address - Phone:763-443-1286
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE. N.
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL066017-8164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse