Healthcare Provider Details

I. General information

NPI: 1497148225
Provider Name (Legal Business Name): DIANNE LARSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 KINGSLEY AVE SUITE 903
ORANGE PARK FL
32073-4466
US

IV. Provider business mailing address

3839 COUNTY ROAD 218
MIDDLEBURG FL
32068-5708
US

V. Phone/Fax

Practice location:
  • Phone: 904-644-8383
  • Fax: 904-644-8289
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-282-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberARNP
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: