Provider Demographics
NPI:1942645148
Name:LARSON, MALLORY MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:MARIE
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 1:70 HURLBUT RD
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-4256
Mailing Address - Country:US
Mailing Address - Phone:906-399-5746
Mailing Address - Fax:
Practice Address - Street 1:300 STATE ROUTE 104
Practice Address - Street 2:SUITE 1
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2956
Practice Address - Country:US
Practice Address - Phone:315-342-0030
Practice Address - Fax:315-216-6669
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308264164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse