Provider Demographics
NPI:1649357385
Name:RAE LARSEN, LESLEY (NMW)
Entity type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:
Last Name:RAE LARSEN
Suffix:
Gender:F
Credentials:NMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MEDICAL VILLAGE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-9835
Mailing Address - Country:US
Mailing Address - Phone:802-334-4110
Mailing Address - Fax:802-334-4113
Practice Address - Street 1:81 MEDICAL VILLAGE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9835
Practice Address - Country:US
Practice Address - Phone:802-334-4110
Practice Address - Fax:802-334-4113
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010030803367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT78119OtherMVP
VT00068564OtherBLUE SHIELD OF VERMONT
VT8000748OtherLADIES FIRST
VT00068564OtherBLUE SHIELD OF VERMONT
VT1011412Medicare ID - Type Unspecified
VT78119OtherMVP