Provider Demographics
NPI:1255163762
Name:LARSON, KORTANI
Entity type:Individual
Prefix:
First Name:KORTANI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3754 DOERING RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9525
Mailing Address - Country:US
Mailing Address - Phone:517-745-5888
Mailing Address - Fax:
Practice Address - Street 1:3754 DOERING RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9525
Practice Address - Country:US
Practice Address - Phone:517-745-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula