Healthcare Provider Details

I. General information

NPI: 1861931032
Provider Name (Legal Business Name): JODI LARSEN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 MINTON RD NW STE 102
PALM BAY FL
32907-1900
US

IV. Provider business mailing address

95 BULLDOG BLVD SUITE 202
MELBOURNE FL
32901-3332
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-1171
  • Fax: 321-724-9024
Mailing address:
  • Phone: 321-727-2990
  • Fax: 321-724-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9323212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: