Healthcare Provider Details

I. General information

NPI: 1043619919
Provider Name (Legal Business Name): JAMIE LARSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 MENAUL BLVD NE
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

9640 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2217
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN01427
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number76474
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55543
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: