Healthcare Provider Details

I. General information

NPI: 1265064620
Provider Name (Legal Business Name): CASSANDRA LARSEN RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 22ND ST
SIOUX FALLS SD
57105-1521
US

IV. Provider business mailing address

1600 W 22ND ST
SIOUX FALLS SD
57105-1521
US

V. Phone/Fax

Practice location:
  • Phone: 605-312-1000
  • Fax: 605-312-1001
Mailing address:
  • Phone: 605-312-1000
  • Fax: 605-312-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number21900541
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: