Provider Demographics
NPI:1427306752
Name:LARSON, KALIE ANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:KALIE
Middle Name:ANN
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 1:370 S 200 E
Mailing Address - Street 2:BSMT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-4608
Mailing Address - Country:US
Mailing Address - Phone:509-389-4172
Mailing Address - Fax:
Practice Address - Street 1:370 S 200 E
Practice Address - Street 2:BSMT
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-4608
Practice Address - Country:US
Practice Address - Phone:509-389-4172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8334450-4701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist