Provider Demographics
NPI:1134828783
Name:LARSON, MICHELLE L (RN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:NEWFARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1188
Mailing Address - Country:US
Mailing Address - Phone:618-997-5311
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041327888163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse