Healthcare Provider Details

I. General information

NPI: 1700835097
Provider Name (Legal Business Name): LISA R LARSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N4405 FRIEDEL AVE
CAMBRIDGE WI
53523-9719
US

IV. Provider business mailing address

N4405 FRIEDEL AVE
CAMBRIDGE WI
53523-9719
US

V. Phone/Fax

Practice location:
  • Phone: 608-692-1141
  • Fax:
Mailing address:
  • Phone: 608-423-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: