Provider Demographics
NPI:1982205514
Name:LARSON, BREANNE L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2101
Practice Address - Street 1:720 N BOND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4952
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0253
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.002925363L00000X, 363LF0000X
IL209020940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209020940OtherAPN