Provider Demographics
NPI:1982614723
Name:LARSON, KIMBERLY S (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
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 1:1573 MALLORY LN
Mailing Address - Street 2:STE 100
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2895
Mailing Address - Country:US
Mailing Address - Phone:615-221-3855
Mailing Address - Fax:615-221-1484
Practice Address - Street 1:170 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9266
Practice Address - Country:US
Practice Address - Phone:307-789-0096
Practice Address - Fax:307-789-0860
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363542-4405363LF0000X
WY18217.0308363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120048800Medicaid
WY120048800Medicaid
UT000012894Medicare ID - Type Unspecified
WY10455Medicare ID - Type Unspecified