Healthcare Provider Details

I. General information

NPI: 1225204282
Provider Name (Legal Business Name): ATHENA LARSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 HOSPITAL DR SUITE 410
LAFAYETTE LA
70503-2852
US

IV. Provider business mailing address

155 HOSPITAL DR SUITE 410
LAFAYETTE LA
70503-2852
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-9700
  • Fax: 337-289-9702
Mailing address:
  • Phone: 337-289-9700
  • Fax: 337-289-9702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP04546
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: