Healthcare Provider Details

I. General information

NPI: 1679390652
Provider Name (Legal Business Name): KIMBERLIE LARSON RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 218-234-6600
  • Fax:
Mailing address:
  • Phone: 218-234-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR38487
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202733
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: