Provider Demographics
NPI:1922567023
Name:LARSEN, NICOLE K (HIS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:LARSEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 N MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1208
Mailing Address - Country:US
Mailing Address - Phone:217-875-5555
Mailing Address - Fax:217-875-9640
Practice Address - Street 1:800 N KELLER DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1739
Practice Address - Country:US
Practice Address - Phone:217-347-5934
Practice Address - Fax:217-347-5939
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3359237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist