Provider Demographics
NPI:1396152583
Name:LARSON, AMY (NP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17445 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9563
Mailing Address - Country:US
Mailing Address - Phone:406-231-4357
Mailing Address - Fax:
Practice Address - Street 1:4151 WILLOWWOOD ST SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-4304
Practice Address - Country:US
Practice Address - Phone:952-226-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25508363LF0000X
MN5097363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily