Healthcare Provider Details

I. General information

NPI: 1073501433
Provider Name (Legal Business Name): HEIDI NOEL LARSON RN, MSN, FNP-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N 13TH AVE
UPLAND CA
91786-4950
US

IV. Provider business mailing address

525 N 13TH AVE
UPLAND CA
91786-4950
US

V. Phone/Fax

Practice location:
  • Phone: 909-982-5111
  • Fax: 909-483-0760
Mailing address:
  • Phone: 909-982-5111
  • Fax: 909-483-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: