Healthcare Provider Details

I. General information

NPI: 1235103045
Provider Name (Legal Business Name): CHRISTINE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 482 BOX 59
FPO AP
96362-0099
JP

IV. Provider business mailing address

PSC 482 BOX 59
FPO AP
96362-0099
JP

V. Phone/Fax

Practice location:
  • Phone: 11-816-1174
  • Fax:
Mailing address:
  • Phone: 11-816-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0002X
TaxonomyHigh-Risk Obstetric Registered Nurse
License NumberRN00147187
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: