Healthcare Provider Details

I. General information

NPI: 1831107663
Provider Name (Legal Business Name): PAULA LYNN LARSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120-B WOODLAND AVE 2ND FLOOR
PHILADELPHIA PA
19142
US

IV. Provider business mailing address

4700 WISSAHICKON AVENUE SUITE 118
PHILADELPHIA PA
19144
US

V. Phone/Fax

Practice location:
  • Phone: 215-727-4721
  • Fax:
Mailing address:
  • Phone: 267-597-3654
  • Fax: 267-597-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTP004902B
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberTP004902B
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN349585L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP004902B
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberTP004902B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: