Provider Demographics
NPI:1720048317
Name:LARSON, NICOLE LYNN (DNP, APRN, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:149 THOMPSON AVE E STE 150
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3238
Practice Address - Country:US
Practice Address - Phone:651-450-0860
Practice Address - Fax:651-450-0759
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1574425163WP0808X
MN1563363LP0808X
MNR157442-5363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q49936Medicare UPIN