Healthcare Provider Details

I. General information

NPI: 1487411302
Provider Name (Legal Business Name): AMY JO LARSEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 RIVERBEND DR
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

346 BROADWAY ST
SPRINGFIELD OR
97477-3019
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-4332
  • Fax:
Mailing address:
  • Phone: 541-513-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10023010
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: