MEDICARE: LISA S. LARSON PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1001592	CO

General Provider Information

NPI Number	:	1174473854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA S. LARSON PMHNP-BC

Provider Business Mailing Address
First Line	:	6330 ASHRIDGE CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-2108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 ASHRIDGE CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-2108
Country	:	US
Telephone Number	:	719-426-8988
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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