Provider Demographics
NPI:1326667833
Name:LARSON, KIRSTEN LYNN (ATC)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21255 LIGHT INFANTRY RD
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918-8074
Mailing Address - Country:US
Mailing Address - Phone:915-741-6365
Mailing Address - Fax:
Practice Address - Street 1:21255 LIGHT INFANTRY RD
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918-8074
Practice Address - Country:US
Practice Address - Phone:915-741-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010020352255A2300X
TXAT99092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000028634OtherBOC