Provider Demographics
NPI:1154929198
Name:LARSON, NICOLE ELIZABETH (LMT)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 OKA ST STE B
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-5332
Mailing Address - Country:US
Mailing Address - Phone:808-828-0030
Mailing Address - Fax:808-977-7769
Practice Address - Street 1:2430 OKA ST STE B
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-5332
Practice Address - Country:US
Practice Address - Phone:808-828-0030
Practice Address - Fax:808-977-7769
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT15434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMAT15434OtherDCCA