Healthcare Provider Details

I. General information

NPI: 1255951166
Provider Name (Legal Business Name): MALORY L LARSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALORY LYNN HARTONG

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/25/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 8TH AVE W
CRESCO IA
52136-1064
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 563-547-2022
  • Fax: 563-547-4340
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10739
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG157504
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: