Healthcare Provider Details

I. General information

NPI: 1336429190
Provider Name (Legal Business Name): NICOLE LARSEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S CLIFF AVE
SIOUX FALLS SD
57105-1007
US

IV. Provider business mailing address

1816 W THOMAS CIR APT 2
BRANDON SD
57005-3037
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-8000
  • Fax:
Mailing address:
  • Phone: 605-660-2915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR000758
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: