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General NPI Number Information
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NPI Number | 1962053017
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Entity Type | Individual
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Provider Name | MIKALA LARSEN
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Gender | Female
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 09/20/2019
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Provider Practice Location Address
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Address Line | 1380 S MEDICAL CENTER DR.
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City | SAINT GEORGE
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State | UT
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Zip | 84790
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Country | US
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Telephone | 435-251-1939
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Fax |
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Provider Business Mailing Address
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Address Line | 1167 E 400 S UNIT 26
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City | SAINT GEORGE
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State | UT
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Zip | 84790-5773
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Country | US
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Telephone | 435-680-0792
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 8500357-4405
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License Number State | UT
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