Healthcare Provider Details

I. General information

NPI: 1679233167
Provider Name (Legal Business Name): COREY LINN LARSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4848 S COMMERCE DR
MURRAY UT
84107-4761
US

IV. Provider business mailing address

1093 E COUNTRYWOODS CIR APT 20F
MIDVALE UT
84047-4154
US

V. Phone/Fax

Practice location:
  • Phone: 385-474-4709
  • Fax:
Mailing address:
  • Phone: 801-664-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9730662-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9730662-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: