Provider Demographics
NPI:1700111788
Name:LARSON, LAURIE L (RN, CNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2992 VANDERBIE ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1225
Mailing Address - Country:US
Mailing Address - Phone:651-470-5276
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 36
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0001
Practice Address - Country:US
Practice Address - Phone:612-273-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1249363LA2100X
MNR1462760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MN500005451Medicare PIN