Healthcare Provider Details

I. General information

NPI: 1326001884
Provider Name (Legal Business Name): MICHELLE A LARSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 WHITE BEAR AVE MAIL STOP 31600A
MAPLEWOOD MN
55109-2798
US

IV. Provider business mailing address

8100 34TH AVE S MAIL STOP 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-779-1500
  • Fax: 651-770-3371
Mailing address:
  • Phone: 952-883-5463
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2047
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: