Healthcare Provider Details

I. General information

NPI: 1023771243
Provider Name (Legal Business Name): ANNA RUTH LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1400
US

IV. Provider business mailing address

1400 MAYFLOWER DR
NORTHFIELD MN
55057-3430
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-2450
  • Fax:
Mailing address:
  • Phone: 612-708-8058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8662
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: