Provider Demographics
NPI:1295293421
Name:LARSON, CHERYL LOUISE (DOMP)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LOUISE
Last Name:LARSON
Suffix:
Gender:F
Credentials:DOMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 TURNER RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-9258
Mailing Address - Country:US
Mailing Address - Phone:218-349-8138
Mailing Address - Fax:218-728-2996
Practice Address - Street 1:1320 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2342
Practice Address - Country:US
Practice Address - Phone:218-349-8138
Practice Address - Fax:218-728-2996
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty