MEDICARE: KIRSTEN LARSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN 5149861	FL

General Provider Information

NPI Number	:	1023212305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN LARSON

Provider Business Mailing Address
First Line	:	1741 SE LORRAINE ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-6540
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 SE LORRAINE ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-6540
Country	:	US
Telephone Number	:	772-337-3490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/08/2007

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