Provider Demographics
NPI:1750136164
Name:LARSEN, CORTNEY TAYLOR (RDN)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:TAYLOR
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 4 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-9207
Mailing Address - Country:US
Mailing Address - Phone:231-519-0273
Mailing Address - Fax:
Practice Address - Street 1:2747 4 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-9207
Practice Address - Country:US
Practice Address - Phone:231-519-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86100007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered