Healthcare Provider Details

I. General information

NPI: 1659349934
Provider Name (Legal Business Name): JANET A LARSON PSYNP, PHD, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

IV. Provider business mailing address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

V. Phone/Fax

Practice location:
  • Phone: 218-768-4011
  • Fax: 218-768-4814
Mailing address:
  • Phone: 218-927-2157
  • Fax: 218-927-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR133861-6
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR133861-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: