Healthcare Provider Details

I. General information

NPI: 1437581121
Provider Name (Legal Business Name): MICHELLE R LARSEN D.V.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE RAPP

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14429 S 41ST PL
PHOENIX AZ
85044-6147
US

IV. Provider business mailing address

14429 S 41ST PL
PHOENIX AZ
85044-6147
US

V. Phone/Fax

Practice location:
  • Phone: 703-281-0765
  • Fax:
Mailing address:
  • Phone: 703-281-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number6166
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: