Provider Demographics
NPI:1003022179
Name:LARSEN, NICOLE MARIE (LAC, MOM)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LAC, MOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST 96TH
Mailing Address - Street 2:APT #2B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5542
Mailing Address - Country:US
Mailing Address - Phone:651-214-1428
Mailing Address - Fax:
Practice Address - Street 1:200 W 96TH ST APT 2B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4328
Practice Address - Country:US
Practice Address - Phone:651-214-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1378171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist