Healthcare Provider Details

I. General information

NPI: 1003022179
Provider Name (Legal Business Name): NICOLE MARIE LARSEN L.AC, M.OM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 96TH ST APT 2B
BLOOMINGTON MN
55420-4328
US

IV. Provider business mailing address

200 WEST 96TH APT #2B
BLOOMINGTON MN
55420-5542
US

V. Phone/Fax

Practice location:
  • Phone: 651-214-1428
  • Fax:
Mailing address:
  • Phone: 651-214-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1378
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: