Healthcare Provider Details

I. General information

NPI: 1538973896
Provider Name (Legal Business Name): KRISTYN MARIE LARSEN MSN, RN, PHN, CPHQ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 MISSOURI FLAT RD
PLACERVILLE CA
95667-6269
US

IV. Provider business mailing address

3931 LOMA DR
SHINGLE SPRINGS CA
95682-8795
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax: 530-621-7713
Mailing address:
  • Phone: 626-664-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number838794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: