Healthcare Provider Details

I. General information

NPI: 1922567023
Provider Name (Legal Business Name): NICOLE K LARSEN HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N KELLER DR
EFFINGHAM IL
62401-1739
US

IV. Provider business mailing address

233 N MAIN ST STE 3
DECATUR IL
62523-1208
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-5934
  • Fax: 217-347-5939
Mailing address:
  • Phone: 217-875-5555
  • Fax: 217-875-9640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3359
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: