=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467169276
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MARIE GALLOIS LARSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2022
-----------------------------------------------------
Last Update Date | 12/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 N DODGE ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53105-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-773-4312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 735044
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-5044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-326-2250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 13310
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 13310
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------