Healthcare Provider Details

I. General information

NPI: 1609551720
Provider Name (Legal Business Name): SARA LARSEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6601
US

IV. Provider business mailing address

1209 W 5000 N
REXBURG ID
83440-3204
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone: 208-249-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberN-42254
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: