Healthcare Provider Details

I. General information

NPI: 1699917039
Provider Name (Legal Business Name): KAE LESLIE LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE L LARSEN RRT

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7521 SW 56TH AVE
GAINESVILLE FL
32608-4402
US

IV. Provider business mailing address

7521 SW 56TH AVE
GAINESVILLE FL
32608-4402
US

V. Phone/Fax

Practice location:
  • Phone: 904-945-5488
  • Fax: 352-378-8602
Mailing address:
  • Phone: 904-945-5488
  • Fax: 352-378-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number5024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: