Provider Demographics
NPI:1265930325
Name:LARSON, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
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 1:123 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1563
Mailing Address - Country:US
Mailing Address - Phone:218-879-1556
Mailing Address - Fax:
Practice Address - Street 1:123 AVENUE C
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6471111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic