Healthcare Provider Details

I. General information

NPI: 1881001840
Provider Name (Legal Business Name): BRANDI LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 22ND AVE
KEARNEY NE
68845-2206
US

IV. Provider business mailing address

804 22ND AVE
KEARNEY NE
68845-2206
US

V. Phone/Fax

Practice location:
  • Phone: 308-455-3600
  • Fax: 308-455-3950
Mailing address:
  • Phone: 308-455-3600
  • Fax: 308-455-3950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number70213
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111691
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: