Provider Demographics
NPI:1063882488
Name:LARSON, MICHELE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 YORBA LINDA BLVD
Mailing Address - Street 2:APT N206
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1755
Mailing Address - Country:US
Mailing Address - Phone:714-318-4537
Mailing Address - Fax:
Practice Address - Street 1:3201 YORBA LINDA BLVD
Practice Address - Street 2:APT N206
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1755
Practice Address - Country:US
Practice Address - Phone:714-318-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist