Provider Demographics
NPI:1922742824
Name:LARSON, MEGAN ELAINE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELAINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16920 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2209
Mailing Address - Country:US
Mailing Address - Phone:612-850-1263
Mailing Address - Fax:
Practice Address - Street 1:16920 23RD AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-2209
Practice Address - Country:US
Practice Address - Phone:612-850-1263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4414133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered