Healthcare Provider Details

I. General information

NPI: 1386232247
Provider Name (Legal Business Name): MELISSA ROSE LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N LAKESIDE DR
LAKE WORTH FL
33460-2307
US

IV. Provider business mailing address

1001 N LAKESIDE DR
LAKE WORTH FL
33460-2307
US

V. Phone/Fax

Practice location:
  • Phone: 609-213-9421
  • Fax:
Mailing address:
  • Phone: 609-231-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN9469534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: