Healthcare Provider Details

I. General information

NPI: 1801299359
Provider Name (Legal Business Name): VICTORIA LARSEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST FL 18
CHICAGO IL
60611-5975
US

IV. Provider business mailing address

1971 SADDLE FARM LN
NAPERVILLE IL
60564-4501
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8624
  • Fax:
Mailing address:
  • Phone: 435-619-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7518943-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN001884
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017415
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: