Healthcare Provider Details

I. General information

NPI: 1376908343
Provider Name (Legal Business Name): MICHELLE LARSEN RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E 200 S
PLEASANT GROVE UT
84062-2923
US

IV. Provider business mailing address

705 E 200 S
PLEASANT GROVE UT
84062-2923
US

V. Phone/Fax

Practice location:
  • Phone: 801-318-6251
  • Fax:
Mailing address:
  • Phone: 801-318-6251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number82899863102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: