Healthcare Provider Details

I. General information

NPI: 1518912989
Provider Name (Legal Business Name): ELIZABETH JORDANNA LARGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 LOMITA DR STE B
MILL VALLEY CA
94941
US

IV. Provider business mailing address

197 LOMITA DR STE B
MILL VALLEY CA
94941
US

V. Phone/Fax

Practice location:
  • Phone: 415-939-2504
  • Fax: 415-389-5424
Mailing address:
  • Phone: 415-939-2504
  • Fax: 415-389-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND92
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: