Provider Demographics
NPI:1295872208
Name:LARSON, LEANN PATRICE (RD)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:PATRICE
Last Name:LARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:PATRICE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3233 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3608
Mailing Address - Country:US
Mailing Address - Phone:651-326-2190
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-326-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2109133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered