Healthcare Provider Details

I. General information

NPI: 1720195167
Provider Name (Legal Business Name): REBECCA ANN LARSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 WOODWARD AVE
IRON MOUNTAIN MI
49801-4631
US

IV. Provider business mailing address

440 WOODWARD AVE
IRON MOUNTAIN MI
49801-4631
US

V. Phone/Fax

Practice location:
  • Phone: 906-776-9040
  • Fax: 906-774-7279
Mailing address:
  • Phone: 906-776-9040
  • Fax: 906-774-7279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704208185
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: