Provider Demographics
NPI:1265918726
Name:LARSEN, NICOLE KAY (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KAY
Last Name:LARSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 N 3RD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2455
Mailing Address - Country:US
Mailing Address - Phone:602-362-2983
Mailing Address - Fax:480-565-4552
Practice Address - Street 1:9225 N 3RD ST STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2455
Practice Address - Country:US
Practice Address - Phone:602-362-2983
Practice Address - Fax:480-565-4552
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP11391207Q00000X
AZAP11391363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine