Provider Demographics
NPI:1255951166
Name:LARSON, MALORY L (ARNP)
Entity type:Individual
Prefix:
First Name:MALORY
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MALORY
Other - Middle Name:LYNN
Other - Last Name:HARTONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:321 8TH AVE W
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1064
Practice Address - Country:US
Practice Address - Phone:563-547-2022
Practice Address - Fax:563-547-4340
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10739363LP0808X
IAG157504363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health