Healthcare Provider Details

I. General information

NPI: 1417331083
Provider Name (Legal Business Name): ELIZABETH LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 POMELO RD W
FORT MYERS FL
33967-3723
US

IV. Provider business mailing address

9025 POMELO RD W
FORT MYERS FL
33967-3723
US

V. Phone/Fax

Practice location:
  • Phone: 239-265-3391
  • Fax:
Mailing address:
  • Phone: 239-265-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9227059
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: