Healthcare Provider Details

I. General information

NPI: 1710232236
Provider Name (Legal Business Name): TIANA J. LARSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WATER ST
BLUE HILL ME
04614-5231
US

IV. Provider business mailing address

57 WATER ST
BLUE HILL ME
04614-5231
US

V. Phone/Fax

Practice location:
  • Phone: 207-374-3940
  • Fax: 207-374-3980
Mailing address:
  • Phone: 207-374-3940
  • Fax: 207-374-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001490
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60401092
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCNM142001
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: