MEDICARE: WILLIE LARSON CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95229614	CA
2	367A00000X	Advanced Practice Midwife	236523	CA

General Provider Information

NPI Number	:	1053062943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE LARSON CNM

Provider Business Mailing Address
First Line	:	5901 RHODES AVE
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1131
Country	:	US
Telephone Number	:	310-869-0906
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 RHODES AVE
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1131
Country	:	US
Telephone Number	:	310-869-0906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	03/11/2025

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