Healthcare Provider Details

I. General information

NPI: 1720998131
Provider Name (Legal Business Name): CALLIE RAE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N
ROBBINSDALE MN
55422-2948
US

IV. Provider business mailing address

3366 OAKDALE AVE N
ROBBINSDALE MN
55422-2948
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-4713
  • Fax:
Mailing address:
  • Phone: 763-581-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06262177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: