MEDICARE: STEPHANIE SHEVANNE LARSEN

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	95035782	CA

General Provider Information

NPI Number	:	1770373383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE SHEVANNE LARSEN

Provider Business Mailing Address
First Line	:	1849 SAWTELLE BLVD STE 610
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7013
Country	:	US
Telephone Number	:	310-361-8043
Fax Number	:	310-986-8241

Provider Business Practice Location Address
First Line	:	10323 SANTA MONICA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6071
Country	:	US
Telephone Number	:	310-730-9236
Fax Number	:	310-469-9073

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

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	03/05/2026

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